Prevention of atrial fibrillation after cardiac surgery: the significance of postoperative oral amiodarone.

STUDY OBJECTIVES: Atrial fibrillation (AF) is a common occurrence after cardiac surgery (10 to 53%) that contributes to increased length of stay and hospital cost. Recent evidence suggests that treatment with amiodarone may provide safe and effective prophylaxis against AF in many patients undergoing cardiac operations. This study sought to investigate whether oral amiodarone administered postoperatively would reduce the incidence of postoperative AF. DESIGN: Prospective nonrandomized cohort study. PATIENTS AND PARTICIPANTS: In this prospective study, 1,196 consecutive patients who underwent various open-heart procedures with cardiopulmonary bypass between July 1999 and February 2000 received oral amiodarone, 400 mg bid, from the transfer to the cardiovascular recovery room until the day of hospital discharge, or up to 7 days postoperatively. The incidence of AF in this group of patients was compared with a group of 1,246 patients who underwent cardiac surgery with cardiopulmonary bypass in the preceding 8-month period (November 1998 to June 1999) at the same institution without receiving amiodarone postoperatively. SETTING: Tertiary health-care center. MEASUREMENT AND RESULTS: AF developed in 294 patients (25%) in amiodarone-treated group and in 385 patients (31%) in the control group (p = 0.001). In multivariate logistic regression analysis, oral amiodarone treatment emerged as an independent predictor of lower risk of AF (odds ratio, 0.7; 95%; 95% confidence interval, 0.6 to 0.9; p = 0.002) and shorter hospital length of stay (odds ratio, 0.8; 95% confidence interval, 0.5 to 0.9; p = 0.006). CONCLUSIONS: Postoperative oral amiodarone treatment is a safe and effective regimen associated with a reduced incidence of new-onset AF and decreased length of hospital stay. Prospective randomized trials are needed to evaluate the benefits of amiodarone treatment relative to its side effect profiles.

Complete myocardial revascularization on the beating heart with epicardial stabilization: anesthetic considerations.

OBJECTIVE: To describe an anesthetic management protocol for patients undergoing cardiac surgery with multiple coronary artery bypass grafts without cardiopulmonary bypass (off-pump CABG surgery) by median sternotomy with mechanical stabilization. DESIGN: Retrospective nonrandomized analysis. SETTING: Tertiary care hospital. PARTICIPANTS: Sixty-six consecutive patients on whom off-pump CABG surgery by median sternotomy was attempted. INTERVENTIONS: Anesthesia was induced with a combination of etomidate and fentanyl; pancuronium bromide was given for muscle relaxation; and anesthesia was maintained with isoflurane, desflurane, or sevoflurane in 100% oxygen. Maintenance of normothermia was attempted by keeping the room temperature at 70 degrees F, warming all fluids to 41 degrees C, and using 2.5 L/min of fresh gas flows and a heat and humidity exchanger. When available, a convective forced-air blanket was used to cover patients' head and shoulders. Patients who were not slated for revascularization of the circumflex vessels and who had good ventricular function received central venous pressure monitoring (26%); all other patients received a pulmonary artery catheter. MEASUREMENTS AND MAIN RESULTS: Of the 66 patients, 36% required an epinephrine infusion at a mean rate of 1.45+/-2.05 microg/min intraoperatively to maintain hemodynamic stability; 25% required inotropic support for < 12 hours in the intensive care unit. CONCLUSION: Institution of systematic hemodynamic management was associated with the successful completion of the surgical procedure in 61 patients (92%). Only 5 patients required conversion to regular CABG surgery with cardiopulmonary bypass.

Tracheopleuropulmonary injuries following enteral tube insertion.

Eighty-three cases of tracheopleuropulmonary injuries complicating enteral tube feeding are analyzed to identify the patterns of injury, and precipitating factors and ways to avoid them. Six new cases observed by the authors and 77 other cases cited in British literature between 1976 and 1987 are presented. In recent years, reports of this complication have been increasing, apparently in a geometrical progression: 8%, 18%, and 74% were reported between 1976 to 1979, 1980 to 1983, and 1984 to 1987, respectively. Sixty-one percent occurred in patients aged 60 years or older. Most of the patients (84%) were seriously ill, which compounded their complications. Seventy-four percent of all injuries were committed by house staff; the narrow bore tube with guide wire was used in 77% of cases. Less than reliable methods were used to confirm tube position in most instances. The presence of cuffed endotracheal tubes did not offer protection. The patients on mechanical ventilation tended to deteriorate if they developed a pneumothorax once the malpositioned tubes were removed. Of the cases reviewed for this report, 18 deaths occurred; 72% being directly related to the tube injuries. Lack of awareness, inadequate confirmatory methods, and insufficient supervision accounted for most of these preventable complications. Educating house/nursing staff in the use of the new tubes, closer supervision, and the application of equal measures of care and caution as employed in other invasive and potentially dangerous procedures are recommended to avoid disastrous outcome.

Anomalous coronary artery originating from the left anterior descending artery and ending in a blind aneurysm.

To the authors' knowledge this is the first report of an anomalous coronary artery originating from the left anterior descending artery and ending in a blind aneurysm.

Computed tomography of strangulated gastric hernia complicated by perforation and pneumothorax.

A case of traumatic rupture of the diaphragm with partial gastric herniation is reported. The initial radiographic presentation was left lower lobe pneumonia. Subsequent strangulation and perforation of the stomach caused pneumothorax. Serial chest radiographs, computed tomography of the chest and abdomen with oral contrast, and a high index of suspicion were instrumental to the diagnosis. Pneumothorax, though rare, must be recognized as a morbid, obstructive phase complication of traumatic diaphragmatic hernia requiring immediate surgical intervention.

Management of a recalcitrant periprosthetic fluid collection.

Axillofemoral bypass grafts have been in common use for more than 20 years in the treatment of severe aortoiliac occlusive disease in poor-risk patients. A persistent periprosthetic fluid collection is an unusual complication of this procedure. We describe a technique by which a tense periprosthetic collection was kept successfully decompressed by the construction of a "window" from the cavity to the peritoneum. In our hands it proved to be safely and easily performed with the patient given local anesthetics; no morbidity occurred.

Coronary artery bypass grafting in a predominately black group of patients.

The preoperative profiles of a predominately non-white group of patients undergoing coronary artery bypass grafting were reviewed. Data were obtained from a retrospective analysis of medical records of 163 patients operated on at Howard University Hospital between July 1983 and July 1986. The analysis was carried out primarily to determine whether patients requiring myocardial revascularization were somehow different from their non-black counterparts. Ninety-one percent of the patients were black, 5 percent white, 0.5 percent Hispanic, and 3.5 percent others (Iranian, Filipino, etc).The study was not designed to review the prevalence of coronary disease in blacks, or to determine the natural history following coronary artery bypass grafting, but to determine whether those with established coronary disease of such a severity as to warrant revascularization had the usual clustering of risk factors. Patient records were reviewed to determine the prevalence of hypertension, diabetes, obesity, cigarette smoking, previous myocardial injury, and total serum cholesterol. Because of the well-recognized increased incidence of hypertension in black patients, and its role as a major risk factor in coronary heart disease, the sequelae of hypertension were considered in relation to results of surgical therapy.The study population included 93 men (57 percent) and 70 women (43 percent); mean age was 59 years (fourth to ninth decade). Seventy-four percent of the patients were hypertensive, 35 percent were diabetic, and 77 percent had a smoking history. Obesity was prevalent among the female patients in general, with 36 percent of the diabetics and 21 percent of the nondiabetics being greater than 50 percent over ideal body weight. Ninety percent of the female patients and 80 percent of the male patients presented with New York Heart Association class III or IV angina. Left ventricular function was, on the average, well preserved. The immediate surgical mortality (following exclusion of patients in extremis) was 4 percent. The surgical mortalities were related to easily identifiable factors. Peri-operative infarctions were profoundly influenced by the presence of diabetes.Although this group was distinguished from most reported groups of patients undergoing aortocoronary bypass grafting by the presence of advanced age, the large percentage of women and diabetics and the marked prevalence of hypertension, and the usual risk factors for coronary artery disease reported in the majority population, the study reconfirms previous epidemiologic findings. It appears that racial "clumping" of a heterogeneous non-white population has minimal usefulness, except as it may be related to socioeconomic status and access to quality health care.

Extended aortic arch anastomosis for repair of coarctation in infancy.

Surgical repair of coarctation of the aorta was performed in 17 infants, median age 14 days, median weight 3.5 kg. Extended end-to-end aortic arch anastomosis was used. A long incision was made in the inferior aspect of the aortic isthmus and arch, which was then anastomosed to the obliquely trimmed distal aorta. The aortic arch was hypoplastic in eight patients. Mean cross-clamp time was 17.1 min. Pulmonary artery bands were placed in five patients. Follow-up two-dimensional echocardiographic and Doppler studies on 13 patients 1 to 56 months after surgery demonstrated normal distal aortic flow in 10, slightly decreased flow in two, and diminished flow in one. Patients with abnormal Doppler flow showed no gradient in one case and a 30 mm Hg gradient in two. Extended aortic arch anastomosis is safe in infancy, leaves no native coarctation shelf tissue in the repaired segment, does not sacrifice the subclavian artery, is useful in hypoplastic isthmus, and is at low risk to develop aneurysm or recoarctation.

Successful treatment of multiple simultaneous great vessel disruptions.

Survival following ruptures of the thoracic aorta at sites other than the aortic isthmus is exceedingly rare. Herein we describe a successful outcome in a 62-year-old woman with ascending and isthmic aortic lacerations compounded by disruptions of the subclavian-innominate artery junction and the left vertebral-subclavian junction. Chest wall instability and a myocardial contusion further complicated her case.

Primary reconstruction of interrupted aortic arch by total aortic outflow obstruction.

Primary aortic arch reconstruction was undertaken in three neonates with interrupted aortic arch and ventricular septal defect. Total ascending aortic occlusion without cardiopulmonary bypass or profound hypothermia permitted, in each case, a rapid tension-free end-to-side descending-to-ascending aortic anastomosis without resulting neurologic or cardiac sequelae. This technique offers distinct advantages over previously described methods and should be considered whenever interrupted aortic arch is present with a ventricular septal defect.

Repair of complex subvalvular aortic aneurysm with a valved conduit.

A subaortic annular aneurysm involving three fourths of the annular circumference was repaired with a valved conduit to which a Teflon felt flange was attached. This unique prosthetic repair assured a strong stable repair and uncompromised coronary flow otherwise unobtainable with previously described repairs.