Long-term outcomes and cost effectiveness of high-dose dexamethasone for cardiac surgery: a randomised trial.

Prophylactic intra-operative administration of dexamethasone may improve short-term clinical outcomes in cardiac surgical patients. The purpose of this study was to evaluate long-term clinical outcomes and cost effectiveness of dexamethasone versus placebo. Patients included in the multicentre, randomised, double-blind, placebo-controlled DExamethasone for Cardiac Surgery (DECS) trial were followed up for 12 months after their cardiac surgical procedure. In the DECS trial, patients received a single intra-operative dose of dexamethasone 1 mg.kg-1 (n = 2239) or placebo (n = 2255). The effects on the incidence of major postoperative events were evaluated. Also, overall costs for the 12-month postoperative period, and cost effectiveness, were compared between groups. Of 4494 randomised patients, 4457 patients (99%) were followed up until 12 months after surgery. There was no difference in the incidence of major postoperative events, the relative risk (95%CI) being 0.86 (0.72-1.03); p = 0.1. Treatment with dexamethasone reduced costs per patient by £921 [€1084] (95%CI £-1672 to -137; p = 0.02), mainly through reduction of postoperative respiratory failure and duration of postoperative hospital stay. The probability of dexamethasone being cost effective compared with placebo was 97% at a threshold value of £17,000 [€20,000] per quality-adjusted life year. We conclude that intra-operative high-dose dexamethasone did not have an effect on major adverse events at 12 months after cardiac surgery, but was associated with a reduction in costs. Routine dexamethasone administration is expected to be cost effective at commonly accepted threshold levels for cost effectiveness.

Planning and monitoring of patients for electrical cardioversion for atrial fibrillation.

OBJECTIVES: This study evaluated the waiting list for elective electrical cardioversion (ECV) for persistent atrial fibrillation (AF), focusing on when and why procedures were postponed. We compared the effects of management of the waiting list conducted by physicians versus management by nurse practitioners (NPs) and we evaluated the safety of our anticoagulating policy by means of bleeding or thromboembolic complications during and after ECV. BACKGROUND: Not all patients selected for ECV receive their treatment at the first planned instance due to a variety of reasons. These reasons are still undocumented. METHODS: We evaluated 250 consecutive patients with persistent AF admitted to our clinic for elective ECV. RESULTS: Within 5 to 6 weeks, 186 of 242 patients (77%) received ECV. The main reason for postponing an ECV was an inadequate international normalised ratio (INR); other reasons included spontaneous sinus rhythm and switch to rate control. A total of 23 of the 147 patients (16%) managed by the research physician were postponed due to an inadequate INR at admission versus 4 out of 98 patients (4%) managed by NPs (p = 0.005) CONCLUSION: An inadequate INR is the main reason for postponing an ECV. Management of ECV by NPs is safe and leads to less postponing on admission.

Echocardiographic diagnosis of left ventricular outflow tract obstruction after mitral valve replacement with subvalvular preservation.

We describe two cases of left ventricular outflow tract obstruction after mitral valve replacement with complete retention of the subvalvular apparatus. The first patient deteriorated immediately after insertion of a high-profile bioprosthesis. In the second patient, chronic left ventricular outflow tract obstruction developed after the insertion of a low-profile mechanical prosthesis. The clinical course of left ventricular outflow tract obstruction after mitral valve replacement with complete retention of the subvalvular apparatus may differ greatly. Evaluation of the left ventricular outflow tract by perioperative transesophageal echocardiography or epicardial echocardiography is essential in the prevention and treatment of this complication.

Effects of preoperative treatment with diltiazem on diastolic ventricular function after coronary artery bypass graft surgery.

OBJECTIVE: To examine whether preoperative treatment with diltiazem could ameliorate left ventricular (LV) diastolic dysfunction in patients after coronary artery bypass graft (CABG) surgery. DESIGN: Prospective, nonrandomized clinical study. SETTING: University hospital. PARTICIPANTS: Thirty-four patients with preserved LV function undergoing elective CABG surgery. INTERVENTIONS: According to medical history, patients were divided into 2 groups: patients not receiving diltiazem (n = 17) and patients treated with once-daily oral diltiazem for at least 2 weeks (n = 17). All patients received preoperative beta-blockers. MEASUREMENTS AND MAIN RESULTS: After induction of anesthesia, after sternal closure, and 4 hours after cardiopulmonary bypass (CPB), mitral and pulmonary venous flow velocities were measured with pulsed Doppler. LV short-axis end-diastolic area by Doppler transesophageal echocardiography (TEE) and hemodynamic variables were obtained simultaneously at comparable pulmonary capillary wedge pressures. Postoperatively, increased peak E and A velocities were observed in patients with diltiazem and controls and returned to baseline 4 hours post-CPB in controls. Changes in these velocities did not result in a decreased E/A ratio. Peak A velocity, E/A ratio, and E wave deceleration time were significantly dependent on heart rate, not peak E velocity. End-diastolic area at comparable pulmonary capillary wedge pressure remained unchanged. In relation to diltiazem, only peak A velocity and time velocity integral of the A wave (TVI-A) at 4 hours post-CPB differed from controls. CONCLUSION: Diastolic function is preserved after CABG surgery and is not altered by diltiazem in patients with preserved LV systolic function. The persistence of increased peak A velocity and TVI-A into the postoperative period suggests improved atrial systolic function with diltiazem.

An effective treatment of severe intractable bleeding after valve repair by one single dose of activated recombinant factor VII.

IMPLICATIONS: The successful treatment with recombinant factor VIIa of a patient experiencing intractable bleeding after cardiac surgery is described.

Mini-maze suffices as adjunct to mitral valve surgery in patients with preoperative atrial fibrillation.

INTRODUCTION: After mitral valve (MV) surgery, preoperative atrial fibrillation (AF) often recurs while cardioversion therapy generally fails. Additional Cox maze surgery improves postoperative arrhythmia outcome, but the extensive nature of such an approach limits general appliance. We investigated the clinical outcome of a simplified, less extensive Cox maze procedure ("mini-maze") as adjunct to MV surgery. METHODS AND RESULTS: Thirteen patients with MV disease and preoperative AF were treated with combined surgery (group 1). Nine control patients without previous AF underwent isolated MV surgery (group 2). We retrospectively compared the results to findings in 23 patients with preoperative AF who had undergone isolated MV surgery (group 3). In group 1, mini-maze took an additional 46 minutes of perfusion time. One 75-year-old patient died of postoperative multiple organ failure. Seven patients showed spontaneously converting (within 2 months) postoperative AF. After 1 year, 82% were in sinus rhythm (SR). No sinus node dysfunction was observed. In group 2, all patients were in SR after 1 year. In group 3, only 53% were in SR after 1 year, despite serial cardioversion and antiarrhythmic drug therapy. Exercise tolerance and heart rate were comparable for groups 1 and 2. Left atrial function was present in all but one patient in group 1 and in all patients in group 2 (after MV reconstruction). CONCLUSION: Adding a relatively simple mini-maze to MV surgery improves arrhythmia outcome in patients with preoperative AF without introducing sinus node dysfunction or persistent absence of left atrial function. The results of this type of combined surgery are encouraging and deserve further attention.

Mallory-Weiss tear following cardiac surgery: transoesophageal echoprobe or nasogastric tube?

A case of fatal upper gastrointestinal bleeding from a Mallory-Weiss tear after transoesophageal echocardiography during cardiac surgery is reported. After the echo-cardiographic examination, which is considered a safe procedure, a nasogastric tube was inserted which immediately revealed bright red blood. Eventually the patient lost 9 litres of blood. The role of the echo-probe and the nasogastric tube in causing the Mallory-Weiss tear is discussed. Although this case is not conclusive about the mechanism of oesophageal damage, it is suggested that the safety recommendations for transoesophageal echocardiography also apply for instrumentation of the oesophagus with a nasogastric tube after the transoesophageal echocardiographic examination.

[Partial left ventriculectomy (Batista procedure) for the treatment of terminal heart failure after rejection for heart transplantation]. / Partiële linker ventriculectomie (Batista-operatie) ter behandeling van eindstadium hartfalen na afwijzing voor harttransplantatie.

A woman aged 64 was severely handicapped by dyspnoea due to 'terminal heart failure' resulting from idiopathic dilated cardiomyopathy. The mitral valve was seriously insufficient; the coronary vessels were normal. The patient was not eligible for heart transplantation. Partial left ventriculectomy by Batista's method was performed and the mitral valve replaced by an artificial one. The left ventricular ejection fraction increased from 0.12 before the operation to 0.35 postoperatively and to 0.43 two years later. Patient was then capable of normal exercise (New York Heart Association (NYHA): class I-II). In the Netherlands partial left ventriculectomy is the last surgical option for patients rejected for heart transplantation.

The use of neuromuscular blocking agents in noncardiac surgery after dynamic cardiomyoplasty.

Dynamic cardiomyoplasty is a surgical treatment to improve cardiac performance in patients with end-stage heart failure by wrapping the latissimus dorsi muscle around the heart. The use of skeletal muscle raises concerns about the safety of neuromuscular blocking agents used during general anaesthesia in noncardiac surgery in patients after cardiomyoplasty. We describe the administration of rocuronium to a patient undergoing carotid endarterectomy 18 months after cardiomyoplasty. No clinically relevant effects on haemodynamics were observed. We conclude that the use of nondepolarising neuromuscular blocking agents for noncardiac surgery in patients after cardiomyoplasty does not compromise cardiac performance in a clinically relevant way, although the time between the cardiomyoplasty procedure and the use of nondepolarising neuromuscular blocking agents remains a concern.

The influence of transoesophageal echocardiography on intra-operative decision making. A European multicentre study. European Perioperative TOE Research Group.

The role of transoesophageal echocardiography (TOE) in anaesthesia remains controversial because it is a rapidly evolving technique with few proven benefits and considerable cost. Recently, the Society of Cardiovascular Anaesthesiologists has published practice guidelines for the use of peri-operative TOE. To determine the current role of transoesophageal echocardiography and the relative impact of category-based transoesophageal echocardiographic indications the present study investigated its use in seven Western European countries. The study sample was taken from a prospective cohort of 224 patients with acute or chronic haemodynamic disturbances or at risk of myocardial ischaemia. All patients were monitored with two-lead electrocardiography and radial and pulmonary artery catheters, as well as biplane or multiplane transoesophageal echocardiography. A total of 2232 clinical interventions were made in these patients. The most frequently observed intervention was the administration of a fluid bolus (45% of all interventions). Overall, transoesophageal echocardiography was the most important guiding factor in 560 (25%) interventions. It was the most important monitor in guiding the following therapeutic interventions: anti-ischaemic therapy--207 of 372 interventions (56%); fluid administration--275 of 996 (28%) interventions; vasopressor or inotrope administration--56 of 316 (16%) interventions; vasodilator therapy--six of 142 (4%) interventions and depth of anaesthesia--four of 211 (2%) interventions. We found that transoesophageal echocardiography is frequently influential in guiding clinical decision making and is used most frequently for category II indications but category I indications were associated with more frequent change in management.

[Initial Groningen experiences with dynamic cardiomyoplasty]. / De eerste Groningse ervaringen met dynamische cardiomyoplastiek.

Four patients, one woman and three men aged 48, 62, 49, en 54 years respectively, were subjected to cardiomyoplasty because of medically refractory heart failure secondary to ischaemic or idiopathic dilating cardiomyopathy. The operation and the training period were uncomplicated. In one patient symptoms of heart failure did not improve; the other patients experienced substantial relief of symptoms. However, all three died suddenly within one year after the operation, probably due to ventricular arrhythmias. Cardiomyoplasty may deserve a place in the treatment of heart failure, provided sudden death can be better prevented. Possibly, treatment with an implantable cardioverter-defibrillator might be useful.

The effect of midazolam at two plasma concentrations of hemodynamics and sufentanil requirement in coronary artery surgery.

OBJECTIVES: In this study, the hemodynamics and sufentanil requirement were compared at two midazolam target plasma concentrations in patients undergoing coronary artery bypass grafting (CABG). DESIGN: Prospective, randomized study. SETTING: University hospital, single institution. PARTICIPANTS: Patients undergoing CABG. INTERVENTIONS: Patients were randomly assigned to receive midazolam at a target plasma concentration of 150 ng/mL (group 1; n = 10) or 300 ng/mL (group 2; n = 10). Sufentanil infusion was titrated to maintain hemodynamic stability, defined as mean arterial pressure within 15% of baseline values. All patients received preoperative beta-blocking agents. Arterial blood samples of midazolam and sufentanil were analyzed by high-performance liquid chromatography and radioimmunoassay, respectively. MEASUREMENTS AND MAIN RESULTS: The mean dose of sufentanil (7.5 +/- 1.7 microgram/kg in group 1 v 7.2 +/- 2.5 micrograms/kg in group 2) did not differ. There were no significant differences in hemodynamics between the groups in the period before or after cardiopulmonary bypass (CPB). Before CPB, in two patients in each group, hypertension was controlled with sufentanil only. One patient in group 1 required a vasodilator in addition to sufentanil. No ischemic events occurred before CPB. After CPB, one patient in group 2 required a vasodilator to control hypertension. Two patients in group 2 required treatment with nitroglycerin for myocardial ischemia. Stable plasma concentrations of sufentanil and midazolam were obtained during and after CPB. The midazolam infusion was continued in both groups at a rate of 1.25 micrograms/kg/min during the first 4 postoperative hours. The time to awakening did not differ between the groups (100 +/- 58 minutes in group 1 v 173 +/- 147 minutes in group 2) nor did the plasma concentrations of midazolam (96 +/- 28 ng/mL v 108 +/- 42 ng/mL) at the time of awakening. Intraoperative awareness was not reported. CONCLUSION: In patients undergoing CABG, good hemodynamic control with a similar incidence of hemodynamic interventions was observed at midazolam target plasma concentrations of 150 and 300 ng/mL when coadministered with sufentanil. The sufentanil requirement was identical in both groups. This study suggests that a midazolam plasma concentration of 150 ng/mL is sufficient to provide satisfactory hemodynamic control and to avoid intraoperative awareness.

Failure of anaesthesia after accidental subdural catheter placement.

A case is described where an epidural anaesthetic was complicated by dural puncture, following which attempted conversion to a continuous subarachnoid infusion technique resulted in failure of anaesthesia. Accidental subdural catheter placement was confirmed radiologically, subdural spread of solution being demonstrated; however, only minimal anaesthetic effects were produced.