Postoperative costs associated with outcomes after cardiac surgery with extracorporeal circulation: role of antithrombin levels.

OBJECTIVE: To study the impact on postoperative costs of a patient's antithrombin levels associated with outcomes after cardiac surgery with extracorporeal circulation. DESIGN: An analytic decision model was designed to estimate costs and clinical outcomes after cardiac surgery in a typical patient with low antithrombin levels (<63.7%) compared with a patient with normal antithrombin levels (≥63.7%). The data used in the model were obtained from a literature review and subsequently validated by a panel of experts in cardiothoracic anesthesiology. SETTING: Multi-institutional (14 Spanish hospitals). PARTICIPANTS: Consultant anesthesiologists. MEASUREMENTS AND MAIN RESULTS: A sensitivity analysis of extreme scenarios was carried out to assess the impact of the major variables in the model results. The average cost per patient was €18,772 for a typical patient with low antithrombin levels and €13,881 for a typical patient with normal antithrombin levels. The difference in cost was due mainly to the longer hospital stay of a patient with low antithrombin levels compared with a patient with normal levels (13 v 10 days, respectively, representing a €4,596 higher cost) rather than to costs related to the management of postoperative complications (€215, mostly owing to transfusions). Sensitivity analysis showed a high variability range of approximately ±55% of the base case cost between the minimum and maximum scenarios, with the hospital stay contributing more significantly to the variation. CONCLUSIONS: Based on this analytic decision model, there could be a marked increase in the postoperative costs of patients with low antithrombin activity levels at the end of cardiac surgery, mainly ascribed to a longer hospitalization.

The 'Valve Racket': a new and different concept of atrioventricular valve repair.

OBJECTIVE: Mitral regurgitation due to prolapse of the mitral leaflets frequently compromises annuloplasty repair procedures. We present a new annuloplasty ring that overcomes this difficulty, preventing displacement of the leaflets into the atrium. METHODS: The 'Valve Racket' is a prosthetic ring transformed into a racket by means of handmade mesh using expanded polytetrafluoroethylene (ePTFE Gore-Tex). After transection of the marginal chordae tendineae, five sheep had the new racket implanted in the mitral (n = 3) and in the tricuspid position (n = 2). The surviving sheep underwent postoperative evaluation. RESULTS: After six months of operation, a standard transthoracic study showed competent valves without significant gradients and without residual valve regurgitation. The ring appeared encapsulated by a uniform fibrous tissue but the threads showed a completely denuded surface except in the zone proximal to the ring. Thrombi or calcification deposits in the ring, racket's mesh, or cardiac chamber were not observed. CONCLUSION: This initial experience confirmed the efficacy and simplicity of the technique.

[Cardiac surgery in Jehovah's Witnesses. Experience in Santander, Spain]. / Cirugía cardiaca en testigos de Jehová. Experiencia en Santander.

As patients who are Jehovah's Witnesses are against blood transfusion, they are difficult to manage when a cardiac intervention is required. Between 1998 and 2004, all Jehovah's Witness patients with an indication for cardiac surgery (n=10) were operated on by the same multidisciplinary team. The mean fall in hematocrit was 30% during cardiopulmonary bypass, 35% during the postoperative period, and 22% at discharge. One patient required cardiac re-exploration because of sternal bleeding. All patients survived operation and were discharged. At follow-up, 1 patient died due to respiratory failure. Technological developments that reduce bleeding and enable lost blood to be recovered have made it possible to perform operations involving a risk of hemorrhage in Jehovah's Witnesses.

Surgery for rheumatic tricuspid valve disease: a 30-year experience.

OBJECTIVE: This study was undertaken to assess factors influencing short- and long-term outcomes of surgery for rheumatic disease of the tricuspid valve. METHODS: Between 1974 and 2005, a total of 328 consecutive patients (mean age 51.3 +/- 13.6 years) underwent tricuspid valve surgery for rheumatic disease. There were 12 cases of isolated tricuspid lesion, 199 of triple-valve disease, 114 of tricuspid and mitral valve disease, and 3 of aortic and tricuspid valve disease. Most patients (72%) had predominantly tricuspid regurgitation. Tricuspid valve prosthetic replacement was performed in 31 cases and valve repair in 297. RESULTS: In-hospital mortality was 7.6%. Late mortality was 52.1%, whereas the expected mortality of the Spanish population of the same age was 24.2%. Predictors of in-hospital mortality were male sex, isolated tricuspid lesion, moderate aortic insufficiency, postclamping time, and tricuspid valve replacement. Mean follow-up was 8.7 years (range 1-31 years). Follow-up was 98.9% complete. Predictors of late mortality were age, New York Heart Association functional class IV, postclamping time, and mitral valve replacement. In total, 114 patients required valve reoperation, but only 4 (3.5%) for isolated tricuspid valve dysfunction. At 30 years, actuarial survival was 12.1% +/- 4.4%, actuarial freedom from reoperation was 27.5% +/- 5.8%, and actuarial freedom from valve-related complications was 2.0% +/- 1.3%. CONCLUSION: Organic tricuspid valve disease associated with rheumatic mitral or aortic lesions increases hospital and late mortality, but valve repair compared favorably with valve replacement. Long-term results may be considered acceptable for otherwise incurable valve disease.