"Anaortic" off-pump coronary artery bypass grafting significantly reduces neurological complications compared to off-pump and conventional on-pump surgery with aortic manipulation.

OBJECTIVE: Most studies comparing off-pump coronary artery bypass grafting (OPCAB) with conventional on-pump coronary artery bypass grafting (ONCAB) include patients with aortic manipulation in the OPCAB group. Performing OPCAB without aortic manipulation, i.e., "anaortic" OPCAB (anOPCAB), may improve neurological outcome. METHODS: We reviewed the perioperative data of all isolated CABG patients at two metropolitan hospitals for the period from January 2002 to December 2007. Multiple logistic regression analysis was performed to determine whether the type of procedure was an independent predictor of adverse neurological outcome. RESULTS: Out of a total of 3699 consecutive patients, 1346 were anOPCAB, 600 OPCAB and 1753 ONCAB cases. Neurological complications occurred in 0.9 % of all patients. Compared to the anOPCAB group, there was a statistically significant higher odds for neurological complications in the OPCAB group [odds ratio (OR) 7.01, 95 % confidence interval (CI) 1.4-35.0, P = 0.0175] and in the ONCAB group (OR 12.33, 95 % CI 2.9-52.2, P = 0.0007). CONCLUSIONS: In this series "anaortic" OPCAB surgery significantly decreases the risk of neurological complications compared to both ONCAB and OPCAB with aortic manipulation. If possible, we advocate avoiding aortic manipulation in OPCAB surgery.

Surgical repair of type-A aortic dissection: early and late results in 32 consecutive patients.

BACKGROUND: Acute type-A aortic dissection is a surgical emergency. One unit's experience in the surgical repair of type-A aortic dissection is documented. METHODS: Surgical treatment was undertaken for type-A aortic dissection in 32 consecutive patients between January 1988 and August 1994 at Royal North Shore Hospital. Retrosternal chest pain was the commonest presenting symptom and in four of these cases it was initially misinterpreted as myocardial ischaemia. RESULTS: A total of 24 patients had signs of aortic incompetence on presentation. Computed tomography (CT) scanning was the commonest modality of definitive diagnosis, but trans-oesophageal echocardiography was used as confirmation wherever possible, and we now consider it the initial, best investigation whenever a diagnosis of dissection is considered. There were 15 supra-coronary ascending aortic replacements, and a further four with aortic valve re-suspension. There were 13 operations of the Bentall's type. The overall 30-day mortality was 19%. The late mortality was 19%, with 62% long-term survival at a mean follow-up of 4.8 years. CONCLUSION: Early diagnosis and surgical intervention can give excellent palliation and improved life expectancy in acute type-A aortic dissection.

Outcome in paired recipients of single lung transplants from the same donor.

BACKGROUND AND METHODS: We compared outcome measures in twenty single lung transplant recipients: 10 patients received the first lung of a donor pair (group 1), and 10 patients received the second lung (group 2) to determine the feasibility of sequential use, respectively, of donor lungs from the same donor in the same institution. The paired recipients underwent transplantation in the same operating room by the same surgical team. Both groups were well matched for age, gender, pretransplantation symptom class and diagnosis. RESULTS: The ischemic time for group 1 versus group 2 was 164 +/- 53 minutes (mean +/- standard deviation) (range 103 to 250 minutes) versus 377 +/- 53 minutes (range 315 to 445 minutes), respectively, (p < 0.001), but the longer ischemic time for group 2 did not adversely affect time to extubation (10.5 +/- 5.1 hours versus 10.3 +/- 7.6 hours; p = Not significant), early gas exchange (partial pressure of arterial oxygen on a fractional concentration of oxygen in inspired gas of 0.60: 237 +/- 61 versus 267 +/- 88 mm Hg; p = Not significant), length of hospital stay (16 +/- 13 days versus 16 +/- 5 days; p = Not significant), or actuarial one-year survival (80 +/- 12% versus 90 +/- 12%; p = Not significant). However, acute lung rejection (expressed as events/100 days) was more common within the first 3 months in group 1 versus group 2 (2.68 +/- 0.57 versus 1.32 +/- 0.38, respectively; p < 0.01), as were infectious events (2.07 +/- 0.50 versus 0.99 +/- 0.33; p < 0.01). CONCLUSIONS: These data confirm the safety of using the second lung from a donor pair sequentially in the same institution. The longer cold ischemic time for the second lung does not impair demonstrably early graft function and may be associated with a lower perioperative morbidity from acute rejection and subsequent infection. One-year outcome appears favorable for both groups.

A double-blind placebo-controlled trial of low-dose ganciclovir to prevent cytomegalovirus disease after heart transplantation.

BACKGROUND: The aim of this double-blind, placebo-controlled study was to determine whether a prolonged course of low-dose ganciclovir prevented the development of clinical cytomegalovirus disease after heart transplantation. METHODS: Fifty-six consecutive patients were stratified into two groups: cytomegalovirus-positive recipients (n = 40) and cytomegalovirus-negative recipients of organs from cytomegalovirus-positive donors (n = 16). All patients received equine antithymocyte globulin induction for 7 days and maintenance doses of cyclosporine, azathioprine, and prednisolone. Ganciclovir (5 mg/kg intravenously) or matching placebo was given with the premedication, three times weekly for the first 6 weeks after transplantation and for another 2 weeks for each treated rejection episode between 6 and 12 weeks. RESULTS: Ganciclovir prophylaxis reduced the actuarial incidence of cytomegalovirus disease from 71% to 11% in cytomegalovirus-mismatched patients (p < 0.01). Ganciclovir prophylaxis did not reduce the incidence of cytomegalovirus disease in cytomegalovirus-positive recipients (25% in both placebo and ganciclovir groups) but did delay its onset and reduce its morbidity. There were no adverse reactions during ganciclovir administration. Gastritis was the most common clinical manifestation of cytomegalovirus disease. Pneumonitis and myocarditis were seen only in placebo-treated cytomegalovirus-mismatched patients. All patients with clinical cytomegalovirus disease responded to ganciclovir, 10 mg/kg/day for 2 weeks. CONCLUSIONS: Prolonged low-dose ganciclovir prophylaxis after heart transplantation reduces the incidence of cytomegalovirus disease in cytomegalovirus-mismatched patients and reduces the morbidity of cytomegalovirus disease in cytomegalovirus-positive recipients.

Outcome in peripartum cardiomyopathy after heart transplantation.

From 1983 to 1991, 27 women with peripartum cardiomyopathy were considered for heart transplantation. Of 27 patients, 11 (41%) improved with medical therapy, 10 (37%) underwent transplantation, and six (22%) died. Results in the 10 patients with peripartum cardiomyopathy who underwent transplantation were compared with results in 39 women who underwent transplantation for dilated cardiomyopathy (idiopathic, Adriamycin, valvular, or familial) to determine whether there were differences in survival, rejection, or infection rates. The two groups were, by chance, well matched for number of pregnancies, peak panel reactivity, and cross-match. Mean time from delivery to transplantation was 24 weeks (range 2 to 188 weeks), and this time did not correlate with rejection rates. The linearized rate of rejection from 0 to 3 months was 30% higher in the group with peripartum cardiomyopathy (3.4 +/- 0.7 vs 2.6 +/- 0.3 episodes/100 patient days; p = 0.05). The mean postoperative day to first rejection was day 26 for peripartum cardiomyopathy and day 28 for women with dilated cardiomyopathy. Rejection requiring cytolytic therapy occurred in 40% of women with peripartum cardiomyopathy and 21% of the comparison group (difference not significant). Linearized (treated) infection rates were 1.8 +/- 0.5 for the group with peripartum cardiomyopathy versus 1.5 +/- 0.2 episodes/100 patient days for others (p = 0.05). Actuarial survival was excellent in both groups with 88% and 86% 2-year survival rates, respectively. In conclusion, women who undergo transplantation for peripartum cardiomyopathy have a 30% higher rate of early rejection than do those who undergo transplantation for idiopathic cardiomyopathy and tend to have a greater need for cytolytic therapy. Infection rates are consequently higher.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemorrhoidal ligation. A review of efficacy.

Two hundred forty-one patients undergoing hemorrhoidal rubber band ligation over a five-year period were reviewed to focus on complications. Three patients (1.2 percent) were hospitalized. Two, on oral anticoagulants, recovered from bleeding complications. One patient developed a band-related abscess that resolved with drainage. Twenty patients (8.3 percent) reported pain associated with the procedure. Three patients went on to subsequent surgical hemorrhoidectomy. There were no deaths in the series. This report agrees with previously published series highlighting the efficacy and cost containment of hemorrhoidal ligation. Continued reliance on this approach to hemorrhoidal disease is justified.

Neuromuscular symptoms in elderly patients with hyperparathyroidism: improvement with parathyroid surgery.

In a consecutive series of 100 neck explorations for primary hyperparathyroidism, 42 patients were 60 years of age or older; in this group of elderly patients the surgical cure rate was 100%. These patients were reviewed retrospectively by means of a structure interview. Twenty-one patients had had preoperative neuromuscular symptoms that ranged from coma to subjective muscular weakness. These patients had significantly-higher preoperative serum calcium and parathyroid hormone levels than did 21 patients without neuromuscular symptoms (P = 0.003 and P = 0.046, respectively). Most of the neuromuscular symptoms improved in the postoperative period. In particular, 15 of 17 patients with muscle weakness reported a significant improvement, while 14 of 15 patients who suffered from fatigue and lethargy reported an improvement. An improvement also occurred in the level of day-to-day function in eight patients. While surgery for primary hyperparathyroidism generally is undertaken for a specific indication, such as severe hypercalcaemia or renal stones, it appears from this study that neuromuscular symptoms also may improve, particularly in elderly patients.

Rectal prolapse: relationship with joint mobility.

Joint mobility was assessed in 25 patients who had undergone surgery for complete rectal prolapse and in 25 age- and sex-matched control subjects. A significant increase in extensibility of the fifth finger was found in the patients with rectal prolapse. It was further found that there was a progressive decrease in joint mobility with age in both groups. The pathophysiology of rectal prolapse is complex. Factors considered to be important include rectal intussusception associated with the commonly observed lack of rectal fixation within the sacral hollow, with a deep Pouch of Douglas and weak pelvic floor musculature. The joint hypermobility demonstrated in these patients suggests an underlying connective tissue abnormality which perhaps contributes to the lack of rectal fixation within the pelvis and to the rectal wall intussusception.