Massive bleeding in cardiac surgery. Definitions, predictors and challenges.

BACKGROUND: Severe or massive bleeding in cardiac surgery is an uncommon but important clinical scenario. Its existing definitions are diverse. Its characteristics constantly change during an active hemorrhage and, thus is difficult to define appropriately. METHODS: In this narrative, non-systematic review, we performed a literature search to retrieve data that could contribute to answering clinical questions on the definition and grading of severe hemorrhage and massive transfusion, identifying factors that predict and affect bleeding and transfusion-related mortality and describing the risks of re-exploration and the economic impact of severe bleeding in cardiac surgery.   Results: Massive perioperative bleeding is currently described by indices of its rate and extent and the magnitude of the consequent blood products transfusion. It has a significant impact on mortality, service logistics, and hospital financing. Proper and early identification of a massive bleeding is possible. Among other factors, patient's co-morbidities, bleeding severity and transfusion volume seem to predict the associated mortality. Consequent to severe bleeding, re-exploration, is also a potentially hazardous adverse event that also affects morbidity and mortality. CONCLUSIONS: Severe perioperative hemorrhage in cardiac surgery carries significant morbidity and mortality. Currently, prediction and identification of massive bleeding is a feasible but incomplete clinical task despite the availability of effective treatment regimens. A still missing, compact definition of massive perioperative bleeding in cardiac surgery that incorporates all phases of treatment could augment clinical preparedness, allow for the development of accurate prediction tools and permit the application of well-validated protocols of management. Hippokratia 2016, 20(3): 179-186.

Aortic false aneurysm at the distal anastomotic suture line after aortic arch replacement; a case report with review of the literature.

Anastomotic pseudoaneurysm remains one of the main life-threatening complications after surgery on the thoracic aorta. We report a case with a history of ascending and aortic arch replacement and a false aneurysm creation at the anastomotic line found at the 2-year follow-up computed tomography. Either, due to incidental and asymptomatic finding and patient negation to any kind of intervention, it has been followed the medical treatment with blood pressure and heart rate control. In this, we discuss also the ways of treatment and the indication of any interventional therapy. Endovascular stent-grafting is a minimal invasive treatment for thoracic aortic aneurysm. However, its clinical usefulness for anastomotic false aneurysm following thoracic aortic surgery is unclear.

A mass in the posterior mediastinum; extramedullary haemopoietic tissue.

Extramedullary haematopoiesis is a very rare cause of a posterior mediastinal tumour and may be clinically confused with many other mediastinal tumours; benign or malignant. Extramedullary haematopoiesis is a really rare cause of haemothorax and usually it is diagnosed incidentally. Extramedullary masses complicating thalassemias, apart from the known complications, may also bleed and produce acute manifestations like dyspnoea and fatigue. Pathologically, the masses are soft, deep red, and resemble spleen tissue on the cut surface. Histologically, they are formed of hematopoietic tissue mixed with adipose elements. The mass is extremely vascular and contains some fibrous tissue. This particular structure renders the mass prone to haemorrhage. We report a case of posterior mediastinal extramedullary haematopoietic mass in a 56-year-old man who presented with non-specific symptomatology and a paravertebral mass on chest X-ray and in the chest computed tomography. A percutaneous biopsy approach could be technically difficult due to the special location of the mass. Video assisted thoracic surgery (VATS), is a minimal invasive and alternative way of diagnosis, biopsy and treatment of these cases. Diagnosis was achieved in our patient by mini thoracotomy and open biopsy in order to prevent bleeding or neurological damage.

The systemic inflammatory response in coronary artery bypass grafting: what is the role of the very low ejection fraction (EF < or = 30%)?

AIM: Patients with depressed left ventricular function are more susceptible to develop postoperative complications after cardiac surgery. The aim of the present study was to examine the effect of severe left ventricular dysfunction on the activation of systemic inflammatory reaction during and after coronary artery bypass grafting (CABG). METHODS: Clinical prospective study; 32 selected patients underwent CABG; 16 patients had depressed left ventricular function before the operation (low ejection fraction [EF] <30%)--Low EF group (study group). Sixteen patients had normal left ventricular function (normal EF, >50%)--Normal EF group (control group). The levels of inflammatory mediators TNF-alpha, IL-6, IL-8 and IL-10 were measured preoperatively, during and after cardiopulmonary bypass (CPB) and 24 hours postoperatively. RESULTS: Higher levels of almost all of inflammatory mediators were detected in patients with depressed left ventricular function compared with patients of normal EF group. IL-6 levels were found statistically significant higher in Low EF group before the induction of anesthesia (P=0.039) and after the administration of protamine (P=0.02). IL-8 levels were found statistically significant higher in Low EF group before the induction of anesthesia (P=0.05), 30 min after the start of CPB (P=0.02), after the administration of protamine (P=0.015) and 24 hours after the end of the operation (P=0.05). No statistically significant differences were demonstrated between the 2 groups of study relative to TNF-alpha and IL-10. CONCLUSION: A greater activation of systemic inflammatory reaction occurred in patients with depressed left ventricular function than in patients with normal cardiac function when they underwent CABG with extracorporeal circulation.

"Learning curves" of cardiac surgery in relation to risk stratification and hospital location.

AIM: The purpose of this study was to determine any significant differences in "learning curves" between private and public hospitals when the same senior surgeon was responsible during the initial phases of open-heart surgery programs development, in relation to risk stratification and hospital location. METHODS: A prospective review of 610 patients records was performed at a newly-opened cardiothoracic program in a public University Hospital (PUH) in the periphery of Greece, and a private institution (PI) with an experienced intensive care unit (ICU) in the capital city of Athens. Preoperative risk stratification, mortality and postoperative length of stay (LOS) were analysed between 1999 to 2001. RESULTS: At PUH 298 patients were operated and 312 patients at PI. There were 136 low risk (EuroSCORE 0-2) and 474 medium and high-risk patients (EuroSCORE > or =3). There was no significantly elevated mortality or learning curve in low risk surgery either at PUH (57 patients with 1 death) or PI (79 patients and 1 death). In medium and high-risk surgery at PI there was no mortality in 68 patients operated by the senior surgeon and no learning curve in all 233 such patients. In 240 medium and high-risk patients at PUH there was a learning curve despite the involvement of the same senior surgeon. In 1999 and 2000 the observed mortality (OM) in 150 patients was 15.33%, EuroSCORE 5.98, and in 2001 in 91 patients OM 3.29%, EuroSCORE 5.95 with p=0.00.8 when "experienced" ICU staff was employed. LOS was significantly reduced in 97 patients in 2001 at PUH (8.7 d +/- 2.81 vs 11.07 days +/- 7.9 in 1999 and 2000, p=0.046) confirming the existence of a learning curve at the PUH. No such change was observed at PI (8.2 days vs 7.8, p=0.45). CONCLUSION: No mortality differences or learning curve characteristics were detected for low risk operations either at PUH or PI. For medium and high risk surgery there appears to be a learning curve in PUH but not in PI despite senior surgeon involvement in both. The presence of an experienced ICU appears to play a critical role in the outcome of operations in newly opened cardiothoracic programs.

A study of the effects of extracorporeal circulation on the immunologic system of humans.

OBJECTIVES: The objectives of this study were to quantify the immunosuppressive effects of cardiopulmonary bypass (CPB) and to identify mechanisms responsible for the postoperative immunosuppression of patients undergoing cardiac surgery. DESIGN: A prospective study from 20 consecutive patients. SETTING: The same team operated on all patients in a major teaching hospital, and the immunologic tests were performed in the hospital's hematology laboratory. PARTICIPANTS: Twenty patients were studied who had consented to participate in the study. INTERVENTIONS: All patients underwent valve replacement under general anesthesia. MEASUREMENT AND MAIN RESULTS: The changes in the white blood cell count (WBC), in the B, T, T4, T8 lymphocytes, the concentrations of C-reactive protein (CRP), a1-antitrypsin (A1AT), a2-macroglobulin (A2MG), C3, C4 immunoglobulin A (IgA), IgM, IgG, Kappa (K), and lambda (L) chains were studied. The postoperative immune response was expressed with (1) increased mean axillary temperature (37.5 degrees +/- 0.62 degrees) in the first postoperative 24 hours; (2) increase of WBC (p < 0.001) and T8 (p < 0.01); (3) reduction of C3 (p = 0.01) and A2MG (p < 0.01); (4) reduction of IgA (p < 0.001) and IgG, K, L chains (p < 0.01); and (5) reduction of T (p < 0.01) and T4 (p < 0.01). In the first 24 hours postoperatively, B cells were increased (81%) together with CRP (p < 0.01) and A1AT. CONCLUSIONS: The observed immune alterations were mostly of no immunologic origin and were related to hemodilution and inflammation together with an immunosuppressive effect of trauma and stress.