Antegrade cardioplegia as a possible cause of acute saphenous vein endothelial damage in patients undergoing on pump coronary artery bypass surgery.

BACKGROUND: The administration of antegrade cardioplegia through vein grafts after the completion of each distal anastomosis is a common practice. However, the cardioplegic solution may disrupt the vein endothelium and contribute to late vein graft atherosclerotic disease. This study aimed at evaluating the possible impact of the cardioplegic solution on vein graft endothelium. METHODS: Total of 52 patients (16 women and 36 men) aged 68±8.5 years old that underwent on pump coronary revascularization with at least one vein graft were enrolled. Sections of grafts from the greater saphenous vein were obtained prior to and after delivery of potassium antegrade cardioplegic solution through them. These sections were then examined histologically with immunochemical stain and CD34 index. The endothelial damage and length of vein specimens of both graft sections were evaluated. RESULTS: The endothelial damage of vein specimens appeared to be increased significantly with exposure to antegrade cardioplegia in male and female patients (P from Wilcoxon tests <0.001, for both genders). The increase in the length of vein specimens was significant too (P from Wilcoxon test <0.001 for men and P=0.001 for women). CONCLUSIONS: Antegrade cardioplegia delivered through vein grafts causes substantial damage on vein endothelium. This may have an adverse effect on long-term graft patency.

The impact of disease severity on EQ-5D and SF-6D utility discrepancies in chronic heart failure.

OBJECTIVES: To compare EQ-5D and SF-6D utilities across groups of chronic heart failure (CHF) patients with varying levels of disease severity. METHODS: A consecutive sample (N = 251) of CHF patients undergoing elective cardiac surgery were surveyed. Disease severity was proxied via a self-assessment scale, the EQ-VAS and the Duke Activity Status Index (DASI); however, validity was demonstrated only by the latter. Association and level of agreement between instruments in DASI-based severity groups were estimated with Pearson's r and the intraclass correlation coefficient (ICC), respectively. Paired-samples t test was used to identify significant differences. In a linear regression model, the DASI was used as an anchor of disease severity to identify a potential "crossover" point between EQ-5D and SF-6D utilities. RESULTS: EQ-5D and SF-6D strongly correlated over the entire sample (r = 0.647, P < 0.001); however, their agreement was moderate (ICC = 0.484, P < 0.001). In the less severe DASI groups (i.e. higher functional capacity) EQ-5D was significantly higher than SF-6D (P < 0.001) and differences constituted minimally important differences (MIDs). Contrarily, in the more severe groups SF-6D was predominantly higher than EQ-5D. The regression model indicated a utility crossover point at 0.722 and predicted that individuals with a utility score less than this would score higher on the SF-6D than on the EQ-5D, and vice versa. The DASI score at crossover was calculated at 31.94. CONCLUSIONS: In subgroups of patients differing in CHF severity according to the DASI, mean EQ-5D and SF-6D indices differed significantly. Contrarily, in socio-demographic and clinical groups, these utility differences were not directly evident. According to the evidence, comparisons based on severity classification via a valid disease-specific external instrument may provide insight on instrument choice in cost-utility analyses.

Triple valve endocarditis as an unusual complication of bacterial meningitis.

We report a case of Staphylococcus aureus endocarditis with late onset in a 39-year-old male drug abuser, who presented with bacterial meningitis. Despite resolution of the meningitis as the result of appropriate antimicrobial chemotherapy he developed triple valve endocarditis. Some striking features of this case and a comparison with other reported cases of this uncommon presentation of infective endocarditis are discussed.

Use of continuous subcutaneous anesthetic infusion in cardiac surgical patients after median sternotomy.

UNLABELLED: The use of opioid analgesics to control pain after median sternotomy in cardiac surgical patients is worldwide accepted and established. However, opioids have a wide range of possible side effects, concerning prolonged extubation time, gastrointestinal tract dyskinesia and urinary tract disorders mostly retention. All these may lead to a prolonged ICU stay or overall hospitalization time increase. OBJECTIVE: To determine whether a continuous subcutaneous regional anesthetic infusion delivered directly to the sternotomy site would result in decreased levels of postoperative pain and opioid requirements in cardiac surgical patients undergoing median sternotomy. METHOD: The continuous subcutaneous infusion (OnQ Painbuster system) was applied in 37 patients. 3 patients were exempted due to prolonged ICU stay. 29 patients underwent CABG, 5 had AVR, 1 MVR and modified Maze, 1 patient had a 3-valve repair due to endocarditis and another one had reconstruction of the left ventricle. Requirements of opioid analgesics were recorded for 96 hours after operation. Pain was assessed using the visual analog scale and the total postoperative hospital length of stay was also measured. RESULTS: The postoperative pain was significantly diminished (0 - 3 at VAS). The mean postoperative length of stay was 5,8 days, rather improved compared to the average stay of 6,7 days. CONCLUSION: Continuous subcutaneous infusion of ropivacaine directly at the median sternotomy significantly diminishes postoperative pain and the need for opioid analgesic use. Moreover, it seems to reduce overall postoperative length of stay for all cardiac surgical patients.

Heparin induced thrombocytopenia diagnosis in cardiac surgery: is there a role for thromboelastography?

The aim of the present protocol is to investigate the potency of thromboelastography (TEG) to screen postcardiac heparin induced thrombocytopenia (HIT) patients suspicious for HIT type II, and to differentiate which of them are subject to suffer thrombotic complications from those who will suffer hemorrhagic complications.

Does bilateral internal thoracic artery harvest increase the risk of mediastinitis?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether bilateral internal thoracic artery (BITA) coronary bypass increases the risk for mediastinitis. Using the reported search 140 papers were identified. Twenty-four papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. In general, BITA grafting carries a 2.5- to 5-fold higher risk for mediastinitis after CABG. This risk is about 1.3-4.7% in non-diabetic patients compared to 0.2-1.2% for single internal thoracic artery (SITA) grafting. For diabetic patients with BITA grafting the risk of mediastinitis is significantly increased and can be as high as >10% in some series. However, for patients who undergo BITA harvest using skeletonization the risk is significantly lower and may be similar to patients receiving SITA graft only at around 0.4-2.6%. BITA grafting can be performed with acceptable risk in all patients including higher risk patients such as diabetics, in whom skeletonization of the internal thoracic arteries should be strongly considered rather than pedicled harvest.

Can thromboelastography predict which patients with heparin-induced thrombocytopenia may suffer thrombotic complications of type II?

Despite the existence of several sensitive functional and antigen assays used for the diagnosis of heparin-induced thrombocytopenia (HIT), an additional assessment of the patient's hemostatic status, in order to predict the thrombotic complications of the malevolent HIT type II, has become necessary. Herein below, we present the findings of thromboelastography (TEG) in a post-cardiac-surgery patient with the clinical diagnosis of HIT type II and false negative tests for heparin antibodies. We have reached the conclusion that TEG may prove to be a useful supplementary method to predict those HIT patients who may suffer complications of HIT type II.

Cervical mediastinoscopy and anterior mediastinotomy in superior vena cava obstruction.

STUDY OBJECTIVES: There is general agreement regarding the diagnostic efficacy of cervical mediastinoscopy (CMDS) and anterior mediastinotomy (AMDT) on patients with superior vena cava obstruction (SVCO), but controversy exists concerning the safety of these two diagnostic methods on that particular subset of patients. The purpose of the present study is to evaluate the safety and diagnostic efficacy of CMDS and AMDT in patients with SVCO. MATERIALS AND METHODS: During the last 28 years, 39 consecutive patients with SVCO underwent biopsy of mediastinal lesions by CMDS (n = 18) or AMDT (n = 19) or both these techniques (n = 2). The medical records of all patients were reviewed, and demographic data, operative notes, perioperative complications, outcome, and histologic diagnoses were examined. The findings were compared with those of 367 patients without SVCO who underwent biopsy of mediastinal lesions during the same period of time. An up-to-date English-language literature search was performed. RESULTS: The sensitivity of CMDS and/or AMDT in detecting malignancies in 39 patients with SVCO was 97.4%, specificity was 100%, and diagnostic accuracy was 97.4%. There was no in-hospital mortality, while morbidity consisted of five major complications and one minor complication, including two major hemorrhages and two airway obstructions. These patients, compared to those without SVCO, showed significantly higher postoperative morbidity (p < 0.001) and had a higher rate of malignancy (p < 0.001). Among 280 patients of the literature review, major hemorrhage was recorded in eight cases and airway obstruction in none. CONCLUSIONS: CMDS and AMDT are effective methods to establish a histologic diagnosis in patients with SVCO. Although their mortality is negligible, they are accompanied by a significantly higher morbidity compared to patients without SVCO. Airway obstruction is a life-threatening complication that can occur in these patients. In our series, patients with SVCO had a higher rate of malignancy compared to patients without SVCO.

AIDS-related cardiac tamponade: is surgical drainage justified?

In order to evaluate the usefulness of surgical drainage in the treatment of patients with acquired immunodeficiency syndrome (AIDS)-related cardiac tamponade, we reviewed our experience with subxiphoid pericardiostomy on 5 consequent such patients. One patient died in the immediate postoperative period and the remaining 4 died within 21 weeks after the operation. Similar results have been reported by other authors who found that surgical drainage has no diagnostic or therapeutic benefit over pericardiocentesis in this particular group of patients. Based on our limited experience and the data of the literature, we feel that surgical drainage cannot be justified as the primary method of treatment of AIDS-related cardiac tamponade.

Management of 150 flail chest injuries: analysis of risk factors affecting outcome.

OBJECTIVE: Flail chest continues to be an important injury with significant complications. The records of 150 patients presenting with flail chest injury were reviewed to determine risk factors affecting morbidity and mortality. MATERIAL AND METHOD: During a 7-year period 150 patients with a flail chest injury were admitted to our trauma center. There were 111 men (74%) and 39 women (26%) ranging in age from 18 to 88 years with a mean age of 56.9. Only 66 (44%) had an isolated flail chest injury on admission. The majority of patients were older than 55 years (n = 89, 59.3%), 80 (53.3%) presented with an hemo-, or/and pneumothorax, 36 (24%) sustained a head injury and 25 (16.7%) needed ICU monitoring. The mean ISS score was 38. Age, concomitant diseases, presence of pneumothorax and/or hemothorax, Severity Score (ISS), the need for mechanical support, length of stay and deaths were evaluated by using the t-test and chi2 test where appropriate. RESULTS: Sixty-seven patients (44.6%) were conservatively treated, while 80 (53.3%) needed thoracic drainage. Only in 6 cases (4%) thoracotomy was required, while in 9 (6%) laparotomy was performed. Mortality rate reached 5.3%. The main factors correlated with an adverse outcome were: ISS and the presence of associated injuries, while age, hemopneumothorax and mechanical support affected the length of hospitalization but not the mortality. CONCLUSIONS: (1) Age and hemopneumothorax did not affect mortality. (2) ISS was found to a strong predictor on outcome concerning morbidity and prolonged hospitalization but did not influence mortality rate. (3) Mechanical support was not considered a necessity for the treatment of flail chest.

Risk factors affecting the survival of patients with pericardial effusion submitted to subxiphoid pericardiostomy.

STUDY OBJECTIVES: Surgical subxiphoid drainage of the pericardial cavity has been established as a safe and effective method of treatment of pericardial effusion; however, the risk factors affecting survival of these patients have not been clarified. The aim of this study was to investigate the risk factors affecting the short-term and long-term survival of patients with pericardial effusion submitted to subxiphoid pericardiostomy. DESIGN: Retrospective study. PATIENTS: The records of all patients who underwent subxiphoid pericardiostomy for treatment of pericardial effusion from January 1991 to December 2001 were reviewed. According to underlying pathology the patients were classified into four groups: (1) hematologic malignancies (n = 17); (2) other malignant diseases (n = 29); (3) AIDS (n = 5); and (4) other benign diseases (n = 53). Multivariate Cox regression analysis was used to test the relationship of short-term and long-term survival to age, sex, cardiac tamponade, pericardial malignant invasion, postoperative low cardiac output syndrome (PLCOS), and underlying pathology. RESULTS: There were 104 patients (59 men) with a mean age of 53.6 years (range, 13 to 85 years). Follow-up was complete in 99 patients (95.2%) for a mean of 23.9 months (range, 0 to 92 months). Overall 30-day mortality was 16.3%, while operation-related mortality was 4.8%. The underlying disease was the main risk factor for short-term and long-term survival (p < 0.00001), while PLCOS was a major predictor of early mortality (p = 0.029). Patients with AIDS showed the worst prognosis. On the contrary, patients with hematologic malignancies presented significantly longer survival compared to all other patients with malignant diseases (p < 0.05). CONCLUSIONS: The underlying disease was the main risk factor for short-term and long-term survival, while PLCOS was a major predictor of early mortality. The prognosis of AIDS patients with pericardial effusion was grave; therefore, surgical intervention in such patients should be reevaluated. Patients with hematologic malignancies had significantly longer survival compared to all other patients with malignant diseases.