Clinical outcomes associated with retrograde arterial perfusion in minimally invasive mitral valve surgery: a systematic review.

INTRODUCTION: Given several reports of an increased neurologic risk with retrograde arterial perfusion in minimally invasive mitral valve surgery, we sought to identify and synthesize the best available evidence on the influence of perfusion strategy on post-operative clinical outcomes in this population. METHODS: A systematic search of PubMed, EMBASE, MEDLINE, and Cochrane library databases was performed to identify publications comparing clinical outcomes associated with antegrade and retrograde arterial perfusion in minimally invasive mitral valve surgery. Pre-specified outcomes of interest were neurologic events, mortality, and renal failure. The search was performed by two independent reviewers, with data abstraction following. RESULTS: Seven observational studies were included in this review, with a total patient population of 5,385. Six were retrospective cohort in design, with a single small prospective cohort study identified. When available, adjusted publication-specific risk estimates were abstracted and included preferentially over unadjusted or reviewer-derived risk estimates. Meta-analysis was felt to be heavily flawed in the context of few small studies identified and was not performed. In adjusted estimates, there appeared to be an increased risk of neurologic complications with retrograde arterial perfusion. There was a null pattern apparent between arterial perfusion strategy and each of 30-day mortality and renal failure. CONCLUSION: Retrograde arterial perfusion in minimally invasive mitral valve surgery may be associated with an increased risk of neurologic events, without affecting the risk of 30-day mortality or renal failure. Although these patterns were identified, an overall paucity of evidence justifies further study.

Reducing Blood Transfusion in Aortic Surgery: A Novel Approach.

BACKGROUND: We introduced a new algorithm utilizing a patient's own platelet rich plasma and factor concentrates to better manage coagulopathy in aortic surgery under circulatory arrest. This study compares the outcomes of the patients treated with a new algorithm with those of patients managed with our traditional approach. METHODS: The data of 247 consecutive patients who had aortic surgery were analyzed. The 158 patients (group 1) who were managed with our usual algorithm were compared with the 89 patients (group 2) who were treated with the novel algorithm consisting of utilization of the patient's own platelet rich plasma, fibrinogen, and prothrombin cell concentrates. Differences in transfusion and intensive care unit stay were analyzed. Univariate and multivariable robust regression analyses were performed. RESULTS: In comparison with group 1, patients in group 2 had significantly reduced need for transfusion of red cells (7.9 ± 8.6 vs 3.5 ± 3.8 units, P < .001). Postoperative intubation time was reduced from a mean of 42 hours to a mean of 12 hours (P < .001). The time to medical discharge from the intensive care unit was reduced from a mean of 7 days to a mean of 5 days (P < .001), favoring the new algorithm. After adjustment for demographics and comorbidities, the novel algorithm remained significantly associated with a reduction in units of red blood cells transfused (robust parameter estimate, -1.14; P = .027) and blood products transfused (robust parameter estimate, -5.11; P < .001). CONCLUSIONS: Using autologous plasma and factor concentrates to reverse coagulopathy in aortic surgery significantly reduces blood product transfusion.

Caecal metastasis from breast cancer presenting as intestinal obstruction.

BACKGROUND: Gastrointestinal metastsasis from the breast cancer are rare. We report a patient who presented with intestinal obstruction due to solitary caecal metastasis from infiltrating ductal carcinoma of breast. We also review the available literature briefly. CASE PRESENTATION: A 72 year old lady with past history of breast cancer presented with intestinal obstruction due to a caecal mass. She underwent an emergency right hemicolectomy. The histological examination of the right hemicolectomy specimen revealed an adenocarcinoma in caecum staining positive for Cytokeratin 7 and Carcinoembryonic antigen and negative for Cytokeratin 20, CDX2 and Estrogen receptor. Eight out of 11 mesenteric nodes showed tumour deposits. A histological diagnosis of metastatic breast carcinoma was given. CONCLUSION: To the best of our knowledge, this is the first case report of solitary metastasis to caecum from infiltrating ductal carcinoma of breast. Awareness of this possibility will aid in appropriate management of such patients.

Randomized trial of carpentier-edwards supraannular prosthesis versus mosaic aortic prosthesis: 6 year results.

BACKGROUND: This study prospectively compares the clinical performance of 2 stented porcine aortic bioprostheses: the Carpentier-Edwards supraannular aortic valve (CE-SAV) from Edwards Lifesciences (Irvine, CA) and the Mosaic valve from Medtronic Corp (Minneapolis, MN). We believe it is the only study of this kind. METHODS: Four hundred three patients undergoing bioprosthetic aortic valve replacement (AVR) between January 2001 and March 2005 were prospectively randomized to receive either the CE-SAV (n = 197) or the Mosaic (n = 206) prosthesis. All patients are being followed annually. RESULTS: The patients in the 2 groups were comparable with respect to their preoperative demographics, EuroSCORE, and their intraoperative characteristics concerning cardiopulmonary bypass. The mean follow-up period was 6 ± 0.25 years, with a total follow-up of 2,418 patient-years. There have been a total of 64 (32.5%) deaths in the group receiving CE-SAV valves and 85 (41.3%) deaths in the group receiving Mosaic valves. The 5-year survival in the 2 groups was 77.7 % and 73.3%, respectively (p = 0.36). There were no statistically significant differences between the 2 groups in terms of structural valve deterioration (SVD) (p = 0.16), paraprosthetic leak (p = 0.13), thromboembolism (p = 0.25), endocarditis (p = 0.68), and freedom from reoperation at 5 years (p = 0.27). Echocardiographic data suggests a trend for lower valve gradients across the 23-mm CE-SAV prostheses compared with similar-sized Mosaic prostheses. CONCLUSIONS: There were no statistically significant differences in the clinical performance between CE-SAV and Mosaic aortic prostheses at 6 years after implantation.

Current practice of antiplatelet and anticoagulation management in post-cardiac surgery patients: a national audit.

The Audit and Guidelines Committee of the European Association for Cardio-Thoracic Surgery recently published a guideline on antiplatelet and anticoagulation management in cardiac surgery. We aimed to assess the awareness of the current guideline and adherence to it in the National Health Service through this National Audit. We designed a questionnaire consisting of nine questions covering various aspects of antiplatelet and anticoagulation management in post-cardiac surgery patients. A telephonic survey of the on-call cardiothoracic registrars in all the cardiothoracic centres across the UK was performed. All 37 National Health Service hospitals in the UK with 242 consultants providing adult cardiac surgical service were contacted. Twenty (54%) hospitals had a unit protocol for antiplatelet and anticoagulation management in post-cardiac surgery. Only 23 (62.2%) registrars were aware of current European Association for Cardio-Thoracic Surgery guidelines. Antiplatelet therapy is variable in the cardiac surgical units across the country. Low-dose aspirin is commonly used despite the recommendation of 150-300 mg. The loading dose of aspirin within 24 h as recommended by the guideline is followed only by 60.7% of surgeons. There was not much deviation from the guideline with respect to the anticoagulation therapy.

Platypnea-orthodeoxia syndrome: a rare complication after right pneumonectomy.

Platypnea is characterized by breathlessness in the upright position. Orthodeoxia is defined by arterial desaturation on standing. Herein we describe a case of platypnea-orthodeoxia syndrome in a patient who underwent a right pneumonectomy for adenocarcinoma of the lung. Closure of a patent foramen ovale, causing a right-to-left shunt, with an Amplatzer device, produced immediate symptomatic relief.

The occult toe: an unusual case of polydactyly in the foot.

We present an unusual case of polydactyly in the foot. The extra digit was hypoplastic, subcutaneous and in an ectopic location.

Peer review practices in biomedical literature: a time for change?

OBJECTIVE: The purpose of this study was to collect the opinions of a cross section of published authors on current practices concerning peer review in biomedical publishing. METHODS: A questionnaire on various aspects of peer review was emailed to authors, whose manuscripts were published in Gut or the British Journal of Surgery between 2001 and 2006. Authors were asked to base their responses on their overall experience with peer review in biomedical literature and not with that one particular journal. RESULTS: Most respondents felt that peer review is an effective quality control mechanism and does help improve manuscripts. Although some felt that it may cause delays in publication, lead to some research being lost and may not prevent all research-related fraud, most authors felt that there was still a strong role for the peer review process as it exists today. CONCLUSION: An overwhelming majority of authors in our study approved of the current peer review practices in biomedical literature. A minority did however seem concerned. We discuss here the surrounding issues.

Spontaneous intramural jejunal haematoma: a case report.

BACKGROUND: Spontaneous intramural intestinal haematoma is a rare complication of anticoagulation therapy. A misdiagnosis may lead to an unnecessary and even hazardous surgical intervention. CASE PRESENTATION: An 85 year old lady presented to us with acute abdomen. She was on Warfarin and was found to have grossly deranged clotting parameters. Computed Tomography Scan revealed a long loop of markedly thick-walled proximal jejunum. A diagnosis of spontaneous intramural jejunal haematoma was made. CONCLUSION: She was successfully treated with conservative management with Vitamin K and blood products.