Advanced Cardiac Resuscitation Evaluation (ACRE): a randomised single-blind controlled trial of peer-led vs. expert-led advanced resuscitation training.

BACKGROUND: Advanced resuscitation skills training is an important and enjoyable part of medical training, but requires small group instruction to ensure active participation of all students. Increases in student numbers have made this increasingly difficult to achieve. METHODS: A single-blind randomised controlled trial of peer-led vs. expert-led resuscitation training was performed using a group of sixth-year medical students as peer instructors. The expert instructors were a senior and a middle grade doctor, and a nurse who is an Advanced Life Support (ALS) Instructor.A power calculation showed that the trial would have a greater than 90% chance of rejecting the null hypothesis (that expert-led groups performed 20% better than peer-led groups) if that were the true situation. Secondary outcome measures were the proportion of High Pass grades in each groups and safety incidents.The peer instructors designed and delivered their own course material. To ensure safety, the peer-led groups used modified defibrillators that could deliver only low-energy shocks.Blinded assessment was conducted using an Objective Structured Clinical Examination (OSCE). The checklist items were based on International Liaison Committee on Resuscitation (ILCOR) guidelines using Ebel standard-setting methods that emphasised patient and staff safety and clinical effectiveness.The results were analysed using Exact methods, chi-squared and t-test. RESULTS: A total of 132 students were randomised: 58 into the expert-led group, 74 into the peer-led group. 57/58 (98%) of students from the expert-led group achieved a Pass compared to 72/74 (97%) from the peer-led group: Exact statistics confirmed that it was very unlikely (p = 0.0001) that the expert-led group was 20% better than the peer-led group.There were no safety incidents, and High Pass grades were achieved by 64 (49%) of students: 33/58 (57%) from the expert-led group, 31/74 (42%) from the peer-led group. Exact statistics showed that the difference of 15% meant that it was possible that the expert-led teaching was 20% better at generating students with High Passes. CONCLUSIONS: The key elements of advanced cardiac resuscitation can be safely and effectively taught to medical students in small groups by peer-instructors who have undergone basic medical education training.

Profound hypothermic cardiac arrest treated successfully using minimally invasive cardiopulmonary bypass: a case report.

BACKGROUND: Hypothermia is defined as a core temperature of less than 35 degrees C. The decision to resuscitate a hypothermic patient can be difficult, as consideration must be given to whether the patient died before the cooling process. The modality for rewarming must also be considered. CASE REPORT: A severely hypothermic 54-year-old man with a core temperature of 21 degrees C was successfully rewarmed using cardiopulmonary bypass via the femoro-femoral route. The patient made a full neurological recovery. CONCLUSION: Cardiopulmonary bypass provides excellent circulatory support for profound hypothermia and allows rapid core rewarming. The femoro-femoral approach is the preferred method for this scenario.

Should we perform preoperative coronary angiography in all cases of atrial myxomas?

The prevalence of coronary disease is high in patients with atrial myxomas yet routine angiography is not performed. Moreover, some tumors have angiographically detectable neovascularity, which can alter surgical planning. We report two cases that support our recommendation for performing coronary angiography in all cases diagnosed with cardiac myxomas.

[Retrospective assessment of influence of pre-and intra-operative risk factors on early and late surgical results in patients with coronary heart disease and severly impaired left ventricle function who underwent coronary artery bypass grafting]. / Retrospektywna analiza wplywu przed- i sródoperacyjnych czynników ryzyka na wczesne i odlegle wyniki chirurgicznego leczenia choroby wiencowej u chorych ze znacznym uposledzeniem funkcji serca.

Aim of the study was to evaluate retrospectively recent and late results of coronary artery bypass grafting (CABG) in patients with ischaemic heart disease and severe left ventricular dysfunction. 146 patients (125 men, 21 women) aged 58.4 +/- 8.4 years, with angina (Canadian Cardiac Society--CCS class > or = 1), heart failure (New York Heart Association--NYHA class > or = 1), left ventricular ejection fraction (LVEF < or = 30%), multi-vessel coronary disease were included to the study. All patients underwent CABG. Peri-operative mortality was 6.1%, in-hospital mortality was 8.2%, 1-year survival was 86.5% and 4-year survival--80%. It was shown that CABG improves angina, dyspnoea and LVEF in patients with coronary heart disease and depressed left ventricle function (LVEF < or = 30%). Selected parameters like: unstable angina requiring intra-aortic balloon pump (IABP) preoperatively, recent heart infarction, cerebrovascular disease, severly depressed left ventricle function (LVEF < or = 20%), mitral regurgitation and Cleveland score > or = 10 pts significantly influence early surgical results (up to 30 days after surgery). It was shown that independent parameters predicting long-term survival and risk of major cardiac events were: negative dobutamine stress test, significant mitral valve incompetence and Cleveland score > or = 10 pts. Use of crystalloid cardioplegia increases early risk of CABG however none of methods of myocardial protection affects long-term surgical results. The outcomes of procedures using blood cardioplegia or intermittent cross clamp and ventricular fibrillation are comparable.

Use of stentless xenografts in the aortic position: determinants of early and late outcome.

BACKGROUND: Whether to perform a stentless aortic valve replacement (AVR) is not well established. Our aim was to determine the outcome after AVR with stentless xenograft valves. METHODS: Between 1996 and 2001, a total of 404 patients (mean age 70.4 years) underwent a stentless AVR by one surgeon in our unit. Concomitant procedures were performed in 132 patients (33%). Twenty patients (6.4%) had undergone previous AVR. Eleven types of stentless xenograft valves were implanted: Medtronic Freestyle in 221 patients (55%), Shelhigh in 55 (14%), Shelhigh composite conduit in 33 (8%), Sorin in 26 (6%), Cryolife O'Brien in 25 (6%), Aortech-Elan in 17 (4%), Edwards Prima in 14 (4%), Toronto SPV in 7 (2%), and other valves in 6 (1%). A subcoronary implantation technique was used in 302 cases (76%), complete root replacement in 62 (15%), and a modified Bentall-De Bono procedure in 33 (8%). Mean follow-up was 19.4 months (range, 1.2 to 60.6 months). RESULTS: Overall hospital mortality was 4.2%. This was 2.4% for isolated AVR, 3.6% for AVR and coronary artery bypass grafting, 5.5% for replacement of two or more valves, and 12% for the modified Bentall procedure. On multiple logistic regression redo cardiac operation (p = 0.0006), cardiogenic shock (p = 0.001), left ventricular ejection fraction less than 0.30 (p = 0.01), modified Bentall procedure (p = 0.03), and endocarditis (p = 0.04) were predictors of in-hospital death. Five-year freedom from thromboembolism, hemorrhage, prosthetic endocarditis, structural valve deterioration, and reoperation was 97%, 99%, 99%, 98%, and 96%, respectively. Kaplan-Meier survival at 5 years was 88%. On Cox regression, cardiogenic shock (p = 0.001) and older age (p = 0.03) were adverse predictors of survival. At echocardiographic examination within 6 months from the operation, mean aortic valve gradients were 15 +/- 6 mm Hg, 12.8 +/- 3 mm Hg, 10.8 +/- 4 mm Hg, 9.3 +/- 3 mm Hg, 9.1 +/- 4 mm Hg, and 8.2 +/- 3 mm Hg for valve sizes of 19, 21, 23, 25, 27, and 29 mm, respectively. CONCLUSIONS: The availability of several stentless valve designs facilitates the surgical treatment of diverse aortic valve or root diseases with encouraging early and mid-term results. Patients requiring concomitant procedures may also benefit from the excellent hemodynamic characteristics of a stentless valve. We consider stentless AVR the treatment of choice for patients older than 60 years and those having small aortic roots.