Peroperative epicardial ultrasonography of distal coronary artery bypass graft anastomoses using a stabilizing device. A feasibility study.

BACKGROUND: Widespread use of intraoperative epicardial ultrasonography (ECUS) for quality assessment of coronary artery bypass graft anastomoses during coronary artery bypass grafting (CABG) has not occurred - presumably due to technological and practical challenges including the need to maintain stable and optimal acoustic contact between the ultrasound probe and the target without the risk of distorting the anastomosis. We investigated the feasibility of using a stabilizing device during ultrasound imaging of distal coronary bypass graft anastomoses in patients undergoing on-pump CABG. Imaging was performed in both the longitudinal and transverse planes. METHODS: Single-centre, observational prospective feasibility study among 51 patients undergoing elective, isolated on-pump CABG. Ultrasonography of peripheral coronary bypass anastomoses was performed using a stabilizing device upon which the ultrasound transducer was connected. Transit-time flow measurement (TTFM) was also performed. Descriptive statistical tests were used. RESULTS: Longitudinal and transverse images from the heel, middle and toe were obtained from 134 of 155 coronary anastomoses (86.5%). After the learning curve (15 patients), all six projections were obtained from 100 of 108 anastomoses scanned (93%). Failure to obtain images were typical due to a sequential curved graft with anastomoses that could not be contained in the straight cavity of the stabilizing device, echo artefacts from a Titanium clip located in the roof of the anastomoses, and challenges in interpreting the images during the learning curve. No complications were associated with the ECUS procedure. The combined ECUS and TTFM resulted in immediate revision of five peripheral anastomoses. CONCLUSIONS: Peroperative use of a stabilizing device during ultrasonography of coronary artery bypass anastomoses in on-pump surgery facilitates imaging and provides surgeons with non-deformed longitudinal and transverse images of all parts of the anastomoses in all coronary territories. Peroperative ECUS in addition to flow measurements has the potential to increase the likelihood of detecting technical errors in constructed anastomoses. TRIAL REGISTRATION: The study was registered on September 29, 2016, ClinicalTrials.gov ID: NCT02919124.

Keep Ventilating the Lungs While the Heart is Still Ejecting on Femoro-femoral Cardiopulmonary Bypass.

Femoro-femoral cardiopulmonary bypass (CPB) followed by deep hypothermic circulatory arrest is one of the modalities used for ascending aortic pseudoaneurysm repair to achieve cardiac unloading and to avoid severe hemorrhage due to the risk of rupture during the sternal entry. However, due to the limited size of the cannulas, it can be challenging to achieve total cardiopulmonary support. Therefore, despite the achievement of total cardiopulmonary support, the heart may still be able to eject antegrade blood flow that meets the retrograde blood flow from the arterial side of the CPB. The point where the blood flow meets in the aorta is called the watershed area. If the antegrade blood flow is large due to a left ventricular ejection, the watershed area will be located in the descending aorta. Therefore, if ventilation is stopped, deoxygenated blood will be ejected to the cerebral circulation. Cerebral near-infrared spectroscopy (NIRS) may be used as a noninvasive and continuous measurement of regional brain oxygen saturation (rSO2). This case demonstrates that cerebral desaturation due to discontinued mechanical ventilation, when the heart was still ejecting during the initial phase of femoro-femoral CPB, immediately was detected by a pronounced drop bilaterally: In the left frontal lobe, rSO2 fell from 56% to 21%, and in the right frontal lobe it fell from 47% to 25%. The authors recommend monitoring cerebral saturation using NIRS in the case of femoro-femoral CPB.

[Bronchoscopic lung volume reduction is a treatment offered to patients with severe heterogenous emphysema]. / Bronkoskopisk lungevolumenreduktion er et behandlingstilbud til patienter med svært heterogent emfysem

Introduction of bronchoscopic lung volume reduction as a treatment for severe emphysema has been defined as an area of development by The Danish Health and Medicines Authority. We here present the rationale for treatment, in- and exclusion criteria, and ultimately the organization for assessment, treatment and follow-up in Denmark. The treatment aim is to lower dyspnoea. There is a national protocol for patient selection according to in- and exclusion criteria. Different commercial devices are available, but endobronchial valves have been the devices mostly applied. A national database has been established to evaluate cost-effectiveness.

[A gastropleural fistula can be treated thoracoscopically].

Gastropleural fistula (GPF) is although uncommon a severe and sometimes fatal complication after prior thoracic surgery, trauma or malignancy. Standard therapy has often included major surgery such as laparotomia with gastrectomi. In this case report we present a patient with GPF who underwent thoracoscopia for closure of the fistula. To our knowledge this is the first report of its kind in the Danish and English literature. Thoracoscopic treatment of GPF may be associated with less morbidity and mortality, and should be considered as the initial procedure of choice.

[Late haemorrhage from truncus brachiocephalicus following tracheotomy]. / Sen blødning fra truncus brachiocephalicus efter trakeotomi.

Haemorrhage following tracheotomy is a well-known complication. Late bleedings from the innominate artery should be considered to indicate a tracheal fistula until proven otherwise. A case with late and massive extratracheal bleeding as a result of pseudoaneurism and erosion of the innominate artery, following facial trauma and emergency tracheotomy is reported. In case of late bleedings from the tracheostoma following trauma in the neck region, the patient should be hospitalized for observation and innominate artery pseodoaneurism should be suspected.

The impact of avoiding cardiopulmonary by-pass during coronary artery bypass surgery in elderly patients: the Danish On-pump Off-pump Randomisation Study (DOORS).

BACKGROUND: Coronary Artery Bypass Graft operation for ischemic heart disease provides improved quality of life and, in some patients, prolonged survival. Concern has, however, been raised about complications that may be related to the use of cardiopulmonary by-pass (CPB) and aortic cross-clamping. It has been hypothesized that when coronary artery by-pass grafting is performed without the use of CPB, the rate of serious complications is reduced. METHODS/DESIGN: The trial is designed as an open, randomized, controlled, clinical trial with blinded assessment of end-points. Patients at or above 70 years of age, referred for surgical myocardial revascularisation, are included and randomised to receive coronary artery by-pass grafting either with or without the use of CPB and aortic cross-clamping. Follow-up is performed by clinical, biochemical, electrocardiographic, and angiographic data that are evaluated by independent committees that are blinded with respect to the result of the randomisation. End points include mortality, stroke, myocardial infarction, graft patency, quality of life, and cost-effectiveness. The trial is performed in four different Danish, cardiac surgery centres. TRIAL REGISTRATION: ClinicalTrials.gov NCT00123981.