A Comparison of the Differences in Postoperative Chronic Pain Between Video-Assisted and Robotic-Assisted Approaches in Thoracic Surgery.

Background and objective In the last decade, there has been significant evolution in thoracic surgery with the advent of robotic surgery. In this study, we aimed to evaluate the incidence of postoperative chronic pain (for six months and beyond) in robotic and video-assisted approaches to analyze the long-term effects of the two different techniques. Methods This was a retrospective study involving 92 patients who underwent various thoracic operations between six months and two years preceding the study. Patients were classified into two groups based on the type of surgery: video-assisted (VATS) (n=51), and robotic-assisted (RATS) (n=41) thoracoscopic Surgery. We employed the EuroQol (EQ-5D-5L) questionnaire to assess the utility values in terms of five quality-of-life measures (self-care, pain/discomfort, mobility, anxiety/depression, and usual activities). Results In the VATS group, the median age was 68 years while it was 57 years in the RATS group (p=0.001). A higher proportion of patients in the VATS group had anatomical lung resection (lobectomy) compared to the RATS group: 61.2 vs. 41.6% respectively (p=0.005). However, the groups were well-matched on other patient characteristics such as relevant past medical history, underlying disease pathology, and final disease staging (if malignant), with no significant differences between groups observed regarding these traits. In the VATS group, 62.7% of patients were pain-free at the time of the questionnaire-based evaluation compared to 51.2% in the RATS group. Additionally, 25.5% vs. 39% of patients had mild pain in the VATS and RATS groups respectively. Neither of these differences was statistically significant. Conclusion Patients who undergo RATS are known to have better recovery and less pain compared to those who have VATS in the immediate postoperative period. However, our results did not find RATS to be superior to VATS in terms of long-term pain. Additionally, robotic surgery is associated with higher hospital costs. In light of these findings, further comparative studies between the two approaches are recommended, while strategies to reduce postoperative pain and financial cost should continue to be explored.

Brachiocephalic artery aneurysm plaque rupture, stroke & repair.

A 70 year old left-handed man presented to his general practitioner with abnormal left arm movements, left hemianopia and loss of balance. He was found to have an isolated brachiocephalic artery aneurysm, measuring 3.5 cm, with associated plaque rupture, contributing to recurrent episodes of transient ischemic attack. He was discussed extensively by a multidisciplinary team. e concurrently had complete occlusion of the right internal carotid artery with distal reconstitution in its supraclinoid segment from collaterals. Stenting of the region would necessitate inappropriately covering the right vertebral artery which would further compromise intracerebral blood. Surgical intervention was deemed the only safe option and he was thus accepted for cardiothoracic surgery. Standard workup revealed left anterior descending artery stenosis. He underwent coronary artery bypass grafting, left atrial appendectomy and brachiocephalic artery resection with replacement with a interposition graft with 10 mm polytetrafluoroethylene graft. He recovered well. This case demonstrates the multi-disciplinary decision making in a rare cause of embolic stroke.

BISMICS consensus statement: implementing a safe minimally invasive mitral programme in the UK healthcare setting.

Disseminating the practice of minimally invasive mitral surgery (mini-MVS) can be challenging, despite its original case reports a few decades ago. The penetration of this technology into clinical practice has been limited to centres of excellence, and mitral surgery in most general cardiothoracic centres remains to be conducted via sternotomy access as a first line. The process for the uptake of mini-MVS requires clearer guidance and standardisation for the processes involved in its implementation. In this statement, a consensus agreement is outlined that describes the benefits of mini-MVS, including reduced postoperative bleeding, reduced wound infection, enhanced recovery and patient satisfaction. Technical considerations require specific attention and can be introduced through simulation and/or use in conventional cases. Either endoballoon or aortic cross clamping is recommended, as well as femoral or central aortic cannulation, with the use of appropriate adjuncts and instruments. A coordinated team-based approach that encourages ownership of the programme by the team members is critical. A designated proctor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases, is an important step to consider. The importance of pre-empting complications and dealing with adverse events is described, including re-exploration, conversion to sternotomy, unilateral pulmonary oedema and phrenic nerve injury. Accounting for both institutional and team considerations can effectively facilitate the introduction of a mini-MVS service. This involves simulation, team-based training, visits to specialist centres and involvement of a designated proctor to oversee the initial cases.

Atrial Tissue Pro-Fibrotic M2 Macrophage Marker CD163+, Gene Expression of Procollagen and B-Type Natriuretic Peptide.

Background Atrial tissue fibrosis is linked to inflammatory cells, yet is incompletely understood. A growing body of literature associates peripheral blood levels of the antifibrotic hormone BNP (B-type natriuretic peptide) with atrial fibrillation (AF). We investigated the relationship between pro-fibrotic tissue M2 macrophage marker Cluster of Differentiation (CD)163+, atrial procollagen expression, and BNP gene expression in patients with and without AF. Methods and Results In a cross-sectional study design, right atrial tissue was procured from 37 consecutive, consenting, stable patients without heart failure or left ventricular systolic dysfunction, of whom 10 had AF and 27 were non-AF controls. Samples were analyzed for BNP and fibro-inflammatory gene expression, as well as fibrosis and CD163+. Primary analyses showed strong correlations (all P<0.008) between M2 macrophage CD163+ staining, procollagen gene expression, and myocardial BNP gene expression across the entire cohort. In secondary analyses without multiplicity adjustments, AF patients had greater left atrial volume index, more valve disease, higher serum BNP, and altered collagen turnover markers versus controls (all P<0.05). AF patients also showed higher atrial tissue M2 macrophage CD163+, collagen volume fraction, gene expression of procollagen 1 and 3, as well as reduced expression of the BNP clearance receptor NPRC (all P<0.05). Atrial procollagen 3 gene expression was correlated with fibrosis and BNP gene expression was correlated with serum BNP. Conclusions Elevated atrial tissue pro-fibrotic M2 macrophage CD163+ is associated with increased myocardial gene expression of procollagen and anti-fibrotic BNP and is higher in patients with AF. More work on modulation of BNP signaling for treatment and prevention of AF may be warranted.

Haemoptysis in an intravenous drug user: injection needle impacted in the left main bronchus.

We report a case of a 35-year-old man who presented with 4-week history of haemoptysis, with a history of intravenous drug use. There was no other significant medical or surgical history and no recollection of any foreign body aspiration. Chest X-ray and CT scan showed 40 mm long needle in left main bronchus, partly lying outside the bronchus into the mediastinum. Flexible and rigid bronchoscopes proved to be unsuccessful in retrieving the needle. We proceeded with left posterolateral thoracotomy and the left main bronchus was explored to take out this 21-gauge (green) injection needle. The distal half of the needle with the sharp end was lying in the mediastinum piercing through the bronchial wall. Surgery was uneventful with good postoperative recovery and the patient was discharged 4 days later.

Cotranscriptional splicing efficiency differs dramatically between Drosophila and mouse.

Spliceosome assembly and/or splicing of a nascent transcript may be crucial for proper isoform expression and gene regulation in higher eukaryotes. We recently showed that cotranscriptional splicing occurs efficiently in Drosophila, but there are not comparable genome-wide nascent splicing data from mammals. To provide this comparison, we analyze a recently generated, high-throughput sequencing data set of mouse liver nascent RNA, originally studied for circadian transcriptional regulation. Cotranscriptional splicing is approximately twofold less efficient in mouse liver than in Drosophila, i.e., nascent intron levels relative to exon levels are ∼0.55 in mouse versus 0.25 in the fly. An additional difference between species is that only mouse cotranscriptional splicing is optimal when 5'-exon length is between 50 and 500 bp, and intron length does not correlate with splicing efficiency, consistent with exon definition. A similar analysis of intron and exon length dependence in the fly is more consistent with intron definition. Contrasted with these differences are many similarities between the two systems: Alternatively annotated introns are less efficiently spliced cotranscriptionally than constitutive introns, and introns of single-intron genes are less efficiently spliced than introns from multi-intron genes. The most striking common feature is intron position: Cotranscriptional splicing is much more efficient when introns are far from the 3' ends of their genes. Additionally, absolute gene length correlates positively with cotranscriptional splicing efficiency independently of intron location and position, in flies as well as in mice. The gene length and distance effects indicate that more "nascent time" gives rise to greater cotranscriptional splicing efficiency in both systems.

Effect of Preoperative Atrial Fibrillation on Postoperative Outcome following Cardiac Surgery.

Atrial fibrillation remains the commonest arrhythmia encountered in cardiac surgery. Data on the effect of preoperative atrial fibrillation on postoperative outcome remain limited. We sought to assess the effects preoperative atrial fibrillation on patients' outcome following cardiac surgery. This is a retrospective review of prospectively collected departmental data of all patients who underwent cardiac surgery over 8-year period. Our cohort consisted of 3777 consecutive patients divided into atrial fibrillation (n = 413, 11%) and sinus rhythm (n = 3364, 89%). Postoperative complications and in-hospital mortality were analysed. Univariate analysis showed significantly increased mortality and major complications in atrial fibrillation compared to sinus rhythm patients. Using multiple logistic regression analysis and after accounting for Euro SCORE as a confounding variable, we found that preoperative atrial fibrillation significantly increases the risk of mortality (OR 1.7), low cardiac output state (OR 1.3), prolonged ventilation (OR 1.4), infective complication (OR 1.5), gastrointestinal complications (OR 2.0), and intensive care unit readmission (OR 1.6). Preoperative atrial fibrillation in cardiac surgery patients increases their risk of mortality and major complications following cardiac surgery. Surgical strategies such as Cox-Maze procedure may be beneficial in these patients.

Gender influence in isolated coronary artery bypass graft surgery: a propensity match score analysis of early outcomes.

INTRODUCTION: The female gender has been shown as high-risk factor for mortality and morbidity. We sought to assess the influence of female gender on coronary artery bypass graft (CABG) surgery from our own experience. METHODS: This is a retrospective analysis of prospectively collected database from a single centre. Patients were grouped according to gender and potential differences in pre-operative, intra-operative and post-operative factors were explored. Significant high-risk factors were then fitted in a multivariate model to account for differences in predicting gender influence on surgical outcomes. RESULTS: Two thousand eight hundred and four consecutive patients underwent isolated first-time CABG between February 2000 and December 2008; 562 (20%) patients were females. Pre-operatively, females were more likely to have significant comorbidities (age, congestive cardiac failure, hypercholesterolemia, hypertension, ischemic heart disease, peripheral vascular disease, pre-op arrhythmias, small body surface area and poor ejection fraction (p < 0.001)) consistent with higher Euroscore (p > 0.0001) and more urgent surgery (p < 0.002). Intra-operatively, they showed less extent pattern of disease requiring less bypass and cross-clamp time (p < 0.001). Observed surgical mortality was significantly higher in females (3.6 vs. 2.1%, p < 0.042); however, after adjusting for propensity score and significant factors identified in multivariate models, females only independently predicted a higher wound infection, lower neurological complications, lower rate of re-sternotomy, longer hospital stay and post-surgery stay (p < 0.01). CONCLUSIONS: Despite higher risk profile and higher observed surgical mortality, early outcomes in females were similar to their matched males' counterpart in isolated CABG surgery. Females were associated with higher incidence of wound infections but lower rate of neurological complications.

Propensity analysis of outcome in coronary artery bypass graft surgery patients >75 years old.

PURPOSE: We looked at the complications and hospital resources of an elderly population undergoing first-time isolated coronary artery bypass graft surgery (CABG) in comparison to a younger counterpart for a propensity matched cohort. METHODS: A retrospective analysis of prospectively collected data was conducted on 2804 CABG patients. Two age groups, >75 years and ≤75 years, were generated. Potential differences in demographic, baseline, preoperative, and intraoperative characteristics were investigated. A propensity score based on these differences was calculated and used to create a matched set of patients. Major postoperative complications were recorded, and data on indicators of resource utilization were collected. RESULTS: In all, 311 (11.1%) patients were identified as >75 years of age. The observed complication rate was significantly higher in overall, pulmonary, cardiac, renal, gastrointestinal (GI), neurological, infective, and mortality categories (P < 0.0001). Observed hospital resource utilization was significant in the elderly group in terms of initial stay in the intensive care unit (ICU) and ICU readmission (P < 0.05) and in all preoperative, postoperative, cardiac surgery, and total hospital stays (P < 0.001). However, after propensity matching to 311 patients ≤75 years, the overall postoperative complication rate maintained its significance (P < 0.0001), in addition to atrial fibrillation and neurological, renal, and GI complications (P < 0.05). Elderly patients required longer duration of ventilation postoperatively and longer postoperative stay, cardiac surgery stay, and total hospital stay; and they maintained a higher surgical mortality rate (6.1% vs. 2.6%) (P < 0.05). CONCLUSION: Elderly patients undergoing CABG had significantly higher rates of postoperative complications. Their prolonged hospital stay and consequently higher resources utilization need to be adequately highlighted to heath care officials and appropriately addressed.

Short-term outcome of solitary kidney patients undergoing on-pump cardiac surgery.

OBJECTIVE: The outcome of patients with solitary kidney undergoing on-pump cardiac surgery is unknown. We sought to assess the in-hospital mortality and complications in these patients compared with patients with normal renal function. METHODS: This is a retrospective review of prospectively collected data over an 8-year period of all patients who underwent cardiac surgery. Our cohort consisted of 3363 consecutive patients divided into: solitary kidney (n=31, 0.9%) and normal kidneys (n=3332, 99.1%). Postoperative complications and in-hospital mortality were analysed. RESULTS: Solitary kidney patients had higher incidence of renal failure (26% vs 5%, p-value<0.001), higher incidence of gastrointestinal complications (10% vs 1%, p-value 0.009) and higher blood transfusions (74% vs 43%, p-value<0.001) compared with patients with normal kidneys. There was an increased length of both intensive care unit stay (3.8 vs 2.2 days, p-value 0.031) and hospital stay (15.6 vs 8.5 days, p-value 0.026) among patients with solitary kidney compared with normal kidney patients. Multivariate analysis showed that solitary kidney is an independent predictor of postoperative renal failure (odds ratio (OR) 7.1 (95%CI 3.1-16.6)), gastrointestinal complications (OR 8.5 (95%CI 2.5-29.4)) and blood transfusion (OR 3.8 (95%CI 1.6-9.0)) after adjusting for age and gender. In-hospital mortality, however, was similar in both groups. CONCLUSION: Although solitary kidney patients have similar short-term mortality as normal kidney patients, the rates of postoperative renal failure, gastrointestinal complications and blood transfusion are significantly higher among solitary kidney patients. Our findings have important clinical implications and prior knowledge of such entity with appropriate risk stratification at admission could help in reducing the risk of these potential complications.

Cross-clamp time is an independent predictor of mortality and morbidity in low- and high-risk cardiac patients.

OBJECTIVES: We sought to assess the effects of aortic cross-clamp time (XCL) on outcome following cardiac surgery in low- and high-risk patients. METHODS: This is a retrospective review of prospectively collected departmental data of all patients who underwent cardiac surgery over 8-year period. Our cohort consisted of 3799 consecutive patients subdivided into low-risk (Euro SCORE < 6, n = 2691, 71%) and high-risk (Euro SCORE ≥ 6, n = 1108, 29%). Each class was further stratified into three groups based on their corresponding XCL time. Group 1 (XCL ≤ 60 min), group 2 (XCL > 60 but ≤ 90 min) and group 3 (XCL >90 min). Postoperative morbidity and in-hospital mortality were analysed. RESULTS: Univariate analysis showed the following to be significantly associated with increased XCL time in both low- and high-risk patients: low cardiac output, prolonged ventilation time, renal complications, prolonged hospital stay, blood transfusion and increased mortality (p < 0.05). By using multiple logistic regression, aortic XCL time >60 min was independent risk factor for low cardiac output, prolonged ventilation, renal complication, blood transfusion, mortality and prolonged hospital stay in both groups. By using XCL time as a continuous variable, an incremental increase of 1 min interval in XCL time was associated with a 2% increase in mortality in both groups. CONCLUSION: Prolonged cross-clamp time significantly correlates with major post-operative morbidity and mortality in both low- and high-risk patients. This effect increases with increasing XCL time. Prior knowledge on this effect can help in preventing some of these complications.

The effect of preoperative renal dysfunction with or without dialysis on early postoperative outcome following cardiac surgery.

OBJECTIVES: Although previous studies have shown increased mortality in renal dysfunction patients undergoing cardiac surgery, there is lack of data on the pattern of postoperative complications that occur in such patients and their distribution among dialysis and non-dialysis dependent renal dysfunction. METHODS: This is a retrospective review of prospectively collected data over 8 year period of cardiac surgery patients. Our cohort consisted of 3598 consecutive patients divided into: normal kidneys (n = 3276, 91%), renal dysfunction (n = 277, 8%) and dialysis (n = 45, 1%). Postoperative complications and mortality were analysed. Multivariate analysis was conducted to adjust for the potential confounders in the association between renal dysfunction and postoperative complications. RESULTS: Univariate analysis showed increased risk of the following complications among renal dysfunction and dialysis patients: low cardiac output, arrhythmias, reoperation, prolonged ventilation, readmission to intensive care, blood transfusion and prolonged hospital stay. Mortality rate was highest in dialysis patients compared to renal dysfunction and normal kidney patients (11% vs. 7% vs. 3%, respectively p-value <0.001). Multivariate analysis showed that renal dysfunction with or without dialysis is an independent predictor of postoperative low cardiac output, blood transfusion, prolonged ventilation, and mortality. The odd ratios were higher for dialysis than non-dialysis dependent patients. This effect persisted after adjusting for potential confounders such as age and gender. CONCLUSION: The presence of renal dysfunction preoperatively increases the rate of postoperative complications and mortality following cardiac surgery. Prior knowledge of these complications can help in developing preventative strategies to reduce the associated risk.

Should cardiac surgery be delayed among carriers of methicillin-resistant Staphylococcus aureus to reduce methicillin-resistant Staphylococcus aureus-related morbidity by preoperative decolonisation?

OBJECTIVES: Preoperative methicillin-resistant Staphylococcus aureus (MRSA) carriage is associated with higher rates of postoperative MRSA infection. Carriage can be eradicated but this requires delaying surgery, which presents a dilemma when the surgery is urgent. We analysed the incidence of preoperative MRSA carriage and the impact on postoperative outcomes in a cardiac surgery population. PATIENTS AND METHODS: Patient data were collected prospectively from 2000 to 2007 (n=3789). MRSA screening is performed at a preadmission clinic for elective patients and on admission to the hospital for all patients. Three groups of MRSA carriers were identified: patients who were identified as carriers at a preadmission clinic (n=22, group 1), patients whose admission screening was positive but where the result was received postoperatively (n=103, group 2) and patients who acquired an MRSA infection or colonisation more than 48 h after admission (n=60, group 3). RESULTS: MRSA eradication measures prior to admission were successful in 21 of 22 in group 1 (95.4%). There were no MRSA infections in group 1. However, in group 2 there were 11 patients with an MRSA infection (10%) even though eradication measures were started on confirmation of carriage. In group 3, 19 of the 60 patients had an MRSA infection. The intensive care stay and mortality were significantly greater in groups 2 and 3 than in group 1 or compared with the overall patient population. However, groups 2 and 3 also had a significantly higher risk profile (European System for Cardiac Operative Risk Evaluation (EuroSCORE)). When matched with similar risk patients, patients in groups 2 and 3 had mortality outcomes that were consistent with matched risk patients. CONCLUSION: Patients who were MRSA carriers were older, more likely to have been on haemodialysis and to have been admitted from another hospital and underwent more complex surgical procedures. Carriage of MRSA was associated with a very high rate of MRSA infection, particularly among patients with diabetes. This suggests that delaying surgery may be warranted in patients expected to require implantation of prosthetic material such as valves, especially with diabetes. However, the survival outcomes for MRSA carriers are determined by their EuroSCORE rather than their MRSA status. This suggests that urgent cardiac surgery should not be delayed in patients with MRSA carriage.

Surgical resection of a renal cell carcinoma involving the inferior vena cava: the role of the cardiothoracic surgeon.

BACKGROUND: The techniques for the resection of renal tumors with IVC extension are based on the experience of individual units. We attempt to provide a logical approach of the surgical strategies in a stepwise fashion. METHODS: Over 6-years 9 patients with renal cell carcinoma invading the IVC, underwent surgery. There were 6 males. The extension was at level IV in 4 and III in 5 cases. CPB used in 8 and hypothermia and circulatory arrest in all patients with level IV disease. The results and an algorithm of the plan of action, as per level of extension are presented. RESULTS: Plan of action: For level I-II disease: No Cardiothoracic involvement, For level III: Cardiopulmonary Bypass (CPB) & control of the cavo-atrial junction. For level IV: use of brief periods of Circulatory Arrest & repair of the Cavotomy with a pericardial patch. Postoperative morbidity: prolonged ICU stay, 3 patients (33.3%); tracheostomy, 1 (11.1%); Sepsis, 2 (22.2%); CVA 1, (11.1%). Mortality: 2 patients (22.2%) CONCLUSIONS: Total clearance of the IVC from an adherent tumor is important, therefore extensive level IV disease presents a surgical challenge.We recommend CPB for level III and brief periods of Total Circulatory Arrest (TCA) for level IV disease.

The risk of arrhythmias following coronary artery bypass surgery: do smokers have a paradox effect?

Smoking is reported to increase the risk of arrhythmias. However, there are limited data on its effects on arrhythmias following coronary artery bypass graft (CABG). This is a retrospective review of a prospective database of all CABG patients over an eight-year period. Our cohort (n=2813) was subdivided into: current (n=1169), former (n=837), and non-smokers (n=807). Predictors of arrhythmias following CABG in relation to smoking status were analysed. Atrial arrhythmias occurred in 942 patients (33%). Ventricular arrhythmias occurred in 48 patients (2%) and high-grade atrioventricular block occurred in five patients (0.2%). Arrhythmias were lower in current smokers than former and non-smokers (29% vs. 40% vs. 39%, respectively P<0.001). Logistic regression analysis showed 30% arrhythmia risk reduction in smokers compared to non-smokers [odds ratio (OR) 0.7, 95% confidence intervals (CI) 0.5-0.8] and this effect persisted after accounting for potential confounders while former smokers had the same risk as non-smokers (OR 1.04, CI 0.9-1.3). There were no significant differences in mortality. Smokers are less prone to develop arrhythmias following CABG. This paradox effect is lost in former smokers. This effect is possibly due to a lower state of hyper adrenergic stimulation observed in smokers than non-smokers following the stress of surgery.

Congenital cystic adenomatoid malformation of the lung: hazards of delayed diagnosis.

Congenital cystic adenomatoid malformation is a rare pulmonary developmental anomaly, which typically manifests in neonates and infants. Presentation in adulthood is uncommon, with <60 cases reported in the literature. The majority of cases involve one lobe only. We report a case of type 1 congenital cystic adenomatoid malformation in an adult presenting with a respiratory tract infection and haemoptysis. At thoracotomy, complex cystic masses were noted in the right upper and lower lobes. Lung-sparing surgery, in the form of two segmentectomies and a non-anatomical resection, was performed in order to avoid pneumonectomy. Such presentations may be problematic as potentially incomplete resections may increase the risk of complications and malignant transformation. This suggests the importance of appropriate clinical and radiological follow up.

Short-term and long-term outcome in low body mass index patients undergoing cardiac surgery.

OBJECTIVE: We sought to assess the effect of low body mass index (BMI) on short- and long-term outcomes following cardiac surgery. METHODS: This is a retrospective review of a prospectively collected departmental database over a 6-year period. Patients were eligible for the study if the BMI was <25 kg/m(2). All morbidities, length of hospital stay, and short- and long-term mortality were reviewed. RESULTS: There were 704 patients divided into low (n = 71) and normal (n = 633) BMI. Postoperative pulmonary complications were higher in the low BMI group compared to the normal BMI group (24% vs. 11%, P < 0.001) with a higher incidence of in-hospital mortality (10% vs. 5%). Using multiple logistic regression, low BMI was an independent risk factor for in-hospital mortality. The 1-, 3-, and 5-year survivals for the low group were 90%, 78%, and 70% compared to 94%, 86%, and 81% in the normal BMI group. CONCLUSION: Low BMI is associated with increased morbidity and mortality following cardiac surgery. Risk scoring systems should utilize the BMI in the preoperative risk assessment with special attention to low BMI.

Effect of smoking on short-term outcome of patients undergoing coronary artery bypass surgery.

BACKGROUND: Data on the effect of smoking on short-term outcome in patients undergoing coronary artery bypass graft (CABG) surgery are limited. We sought to assess the morbidity and in-hospital mortality of smokers and former smokers compared with nonsmokers undergoing CABG. METHODS: This is a retrospective review of prospectively collected departmental data base. In all, 2,587 consecutive patients underwent isolated CABG between February 2000 and June 2007. Of these, 475 patients were current smokers, 1,364 were former smokers of more than 4 weeks, and 748 were nonsmokers. RESULTS: Current smokers had higher rates of postoperative pulmonary complications than former smokers and nonsmokers (30.1% versus 23.3% versus 19.9%, p < 0.001). Blood transfusion requirement was lower for current smokers group than for the other two groups (34.9% versus 37.5% versus 44.1%, p = 0.02). Adjusted odd ratios (OR) for early clinical outcomes showed that current smokers had 59% higher risk of developing pulmonary complications (OR 1.59) than nonsmokers, with former smokers showing an intermediate pattern (OR 1.17). Current smokers had 36% lower risk of postoperative blood transfusion than nonsmokers (OR 0.64), with former smokers showing an intermediate pattern (OR 0.94). Rates of other postoperative complications, intensive care unit readmission, postoperative length of stay, and mortality did not differ among the three groups. CONCLUSIONS: Smoking is associated with significant pulmonary complications after CABG. In-hospital mortality is not influenced by smoking. Smokers should be encouraged to quit before undergoing CABG, and a period of 1 month may be beneficial, given that former smokers in our study seem to have better prognosis than current smokers.

Abiotrophia defectiva endocarditis and associated hemophagocytic syndrome--a first case report and review of the literature.

In this manuscript we describe the first association in the literature between Abiotrophia defectiva endocarditis and the hemophagocytic syndrome. There are multiple important clinical points of information that must be highlighted from this case. A. defectiva is an aggressive organism with a high level of resistance to antibiotic pharmacotherapy with a high predilection for embolic complications and valvular destruction despite treatment with sensitive antibiotics. A. defectiva endocarditis has not been previously associated with the hemophagocytic syndrome. However, this case highlights the serious hematological complications that can occur with this dangerous bacterial pathogen.