Thrombosis of bare metal and patent drug eluting stent in patient operated for colorectal carcinoma: the utility of new guidelines in patients with malignancy.

Percutaneous coronary intervention with stent placement is widely used to achieve revascularization of the myocardium, especially in acute coronary syndrome. There is increasing number of reports published concerning stent thrombosis both in bare metal stents as in drug eluting stents. According to the newest ACC/AHA/SCAI 2007th guidelines, bare-metal stent or balloon angioplasty is recommended as an optimal solution if surgery is to be performed in 6-12 months time after stent placement. We present a case of a 56-year-old male with colon carcinoma who suffered from post-operational myocardial infarction due to bare metal stent thrombosis, while the drug eluting stent remained patent. Currently, in our opinion, high level evidence is lacking in the literature in support for recommendations published in current ACC, AHA and SCAI 2007th guidelines regarding the choice of stent, antiaggregation and anticoagulation therapy. This case, together with others previously published suggests a need for development of an applicable strategy for selection and treatment of patients with increased perioperative risk of in-stent thrombosis in order to ensure optimal medical treatment.

Long-term results after reconstructive surgery for aneurysms of the left ventricle.

BACKGROUND: Aneurysms of the left ventricle (LV) present a serious consequence of myocardial infarction, causing mechanical, thromboembolic, and arythmogenic complications. We present our experience in LV remodeling and long-term follow-up results. METHODS: From May 1998 to February 2009, 85 patients with postinfarction LV aneurysm underwent reconstructive procedures. Mean age was 58.7 + or - 8.9 years (range 36-79 years). Average LV ejection fraction was 39.8% + or - 13.1% (range 20%-70%). Mean EuroScore was 6.0 + or - 2.9 (range 3-19) and predictive mortality was 8.2% + or - 11.9% (range 1.6%-85.6%). The majority of patients were in New York Heart Association functional class II (44%) preoperatively and 32% of patients were in New York Heart Association class III or IV. LV reconstruction was performed by using the endoventricular patch technique in 56 patients (66%). In 29 patients (34%) reconstruction was done by linear closure. In 79 patients (93%) concomitant myocardial revascularization was performed. Mitral valve procedures were performed in 11 patients (13%), (repair in 10 patients and replacement in 1). RESULTS: Perioperative mortality was 3.5% (3 patients). Long-term follow-up was completed by means of phone interview with an average duration of 31.6 months (range 3-120 months). There were 9 late deaths (11%) during follow-up. Actuarial survival rates at 1, 5, and 10 years were 91%, 77%, and 68%, respectively. Fifty-nine patients (72%) were in New York Heart Association functional class I and II postoperatively. CONCLUSION: LV remodeling is a safe surgical procedure with low perioperative morbidity and mortality and excellent long-term survival, even in patients with severely reduced systolic function.

Endoscopic radial artery harvesting reduces postoperative pain and neurologic complications.

BACKGROUND: Endoscopic radial artery harvest provides better cosmetic result without compromising the quality of the graft. We sought to compare postoperative harvesting site neurologic and vascular outcome. METHODS: From 10/2002 until 10/2004, 50 patients were randomized to have their radial artery harvested for coronary bypass either endoscopically (group A, n = 25) or conventionally (group B, n = 25). Radial arteries were preoperatively evaluated by Doppler echocardiography. Neurologic and functional status was assessed by a self reporting questionnaire with a semiquantitative (1-5) scale. Vascular status of the forearm was assessed by control echocardiography. RESULTS: At an average follow-up of 37 +/- 7 months, patients undergoing endoscopic radial artery harvesting had less overall neurologic complications (11 versus 17 patients, P = .023) and they were less severe (0.8 +/- 1.1 versus 2.2 +/- 1.2; P < .001). Ulnar flow increase was similar among the groups: 13.1 +/- 5.43 cm/s in group A versus 15.9 +/- 4.9 cm/s in group B (P = .147) as well as ulnar artery diameter increase 0.29 +/- 0.16 mm in group A versus 0.29 +/- 0.26 cm in group B (P = .914). CONCLUSION: Endoscopic radial artery is safe and does not compromise graft quality or forearm and hand circulation postoperatively. Along with providing a better cosmetic result, endoscopic artery harvesting reduces postoperative harvesting site pain and neurologic complications.

Topical use of antifibrinolytic agents reduces postoperative bleeding: a double-blind, prospective, randomized study.

OBJECTIVE: Postoperative bleeding is still one of the most common complications of cardiac surgery. Antifibrinolytic agents successfully reduce bleeding, but there are controversies concerning adverse effects after their systemic use. By topical application of antifibrinolytic agents in pericardial cavity, most of these effects are avoided. We compared the effects of topically applied aprotinin, tranexamic acid and placebo on postoperative bleeding and transfusion requirements. METHODS: In this single-center prospective, randomized, double-blind trial, 300 adult cardiac patients were randomized into three groups to receive one million IU of aprotinin (AP group), 2.5g of tranexamic acid (TA group) or placebo (PL group) topically before sternal closure. Groups were comparable with respect to all preoperative and intraoperative variables. Postoperative bleeding, transfusion requirements and hematologic parameters were evaluated. RESULTS: Postoperative bleeding within first 12-h period (AP group 433+/-294 [350; 360]ml, TA group 391+/-255 [350; 305]ml, PL group 613+/-505 [525; 348]ml), as well as cumulative blood loss within 24h (AP group 726+/-432 [640; 525]ml, TA group 633+/-343 [545; 335]ml, PL group 903+/-733 [800; 445]ml), showed statistically significant inter-group differences (both p<0.001). Bleeding rates values were significantly higher in placebo group compared to the groups treated with antifibrinolytic agents (AP and TA groups) concerning both variables. Although TA group showed the lowest values, no statistical differences between TA and AP groups were found. Inter-group difference of blood product requirements was not statistically significant. CONCLUSIONS: Topical use of either tranexamic acid or aprotinin efficiently reduces postoperative bleeding. TA seems to be at least as potent as aprotinin, but potentially safer and with better cost-effectiveness ratio.