Innovative use of the octopus stabilizer in the excision of a cardiac hydatid cyst.

Hydatid disease is caused through Echinococcus granulosus infection. Hydatid disease remains endemic in developing countries. The majority of cases involve the lungs or liver. We report the case of a patient diagnosed with concurrent mediastinal and cardiac cysts. In this patient, the Octopus IV cardiac stabilizer was used to rotate the heart after the excision of the mediastinal cyst, enabling the excision of a cyst adherent to left ventricle through a single median sternotomy incision. To date, there have been no reports of the application of the Octopus IV cardiac stabilizer in such a way.

Mitral valve repair in a 55-year-old man with left lung agenesis.

We report on a 55-year-old man who was diagnosed with agenesis of the left lung in childhood. He was essentially asymptomatic until he was 53 years of age, when he became symptomatic with exertional dyspnea due to severe mitral regurgitation. We performed mitral valve repair using a median sternotomy incision approach.

Coronary surgery in patients with peripheral vascular disease: effect of avoiding cardiopulmonary bypass.

BACKGROUND: An increasing number of patients with peripheral vascular disease are undergoing coronary artery bypass grafting. Such patients have an increased risk of adverse outcomes. Our aim was to quantify the effect of avoiding cardiopulmonary bypass in this group of patients. METHODS: Between April 1997 and March 2002, 3,771 consecutive patients underwent coronary artery bypass grafting performed by five surgeons. Four hundred and twenty-two (11.2%) had peripheral vascular disease and of these, 211 (50%) received off-pump surgery. We used multivariate logistic regression analysis to assess the effect of off-pump surgery on in-hospital mortality and morbidity, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score, which was the probability of receiving off-pump surgery and included core patient characteristics. The C statistic for this model was 0.8. RESULTS: Off-pump patients were more likely to have preoperative renal dysfunction, previous gastrointestinal surgery, and less extensive disease. The left internal mammary artery was used more in off-pump compared to on-pump cases (90.1% vs 82.9%; p = 0.033). In the univariate analyses, off-pump patients were less likely to have a postoperative stroke (p = 0.007), and had shorter postoperative hospital stays (p < 0.001). However, the incidence of new atrial arrhythmia was higher (p = 0.028). After adjustment for differences in case-mix (propensity score), avoidance of cardiopulmonary bypass was still associated with a significant reduction in postoperative stroke (adjusted odds ratio 0.09 [95% confidence interval 0.02 to 0.50]; p = 0.005), and shorter postoperative hospital stay (p = 0.001). CONCLUSIONS: Off-pump coronary surgery is safe in patients with peripheral vascular disease, with acceptable results. The incidence of postoperative stroke is substantially reduced when avoiding cardiopulmonary bypass in patients with peripheral vascular disease.

Effect of avoiding cardiopulmonary bypass in non-elective coronary artery bypass surgery: a propensity score analysis.

OBJECTIVE: Non-elective coronary artery surgery (emergent/salvage or urgent) carries an increased risk in most risk-stratification models. Off-pump coronary surgery is increasingly used in non-elective cases. We aimed to investigate the effect of avoiding cardiopulmonary bypass on outcomes following non-elective coronary surgery. METHODS: Of the 3771 consecutive coronary artery bypass procedures performed by five surgeons between April 1997 and March 2002, 828 (22%) were non-elective and 417 (50.4%) of these patients had off-pump surgery. Multivariate logistic regression was used to assess the effect of off-pump on in-hospital outcomes, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score from core patient characteristics, which was the probability of avoiding cardiopulmonary bypass. The C statistic for this model was 0.8. RESULTS: Off-pump patients were more likely to be hypertensive, stable, had less extensive disease and better left ventricular function. The left internal mammary artery was used in 91.8% (n=383) of off-pump patients compared to 79.3% (n=326) of on-pump cases (P<0.001). After adjusting for the propensity score, no difference in in-hospital mortality was observed between off-pump and on-pump (adjusted odds ratio (OR) 0.83 (95% confidence intervals (CI) 0.36-1.93); P=0.667). Off-pump patients were less likely to require intra-aortic balloon pump support (adjusted OR 0.44 (95% CI 0.21-0.96); P=0.039), less likely to have renal failure (adjusted OR 0.44 (95% CI 0.22-0.90); P=0.025), and have shorter lengths of stay (adjusted OR 0.51 (95% CI 0.37-0.70); P<0.001). Other morbidity outcomes were similar in both groups. CONCLUSIONS: In this experience, off-pump coronary surgery in non-elective patients is safe with acceptable results. Non-elective off-pump patients have a significantly reduced incidence of renal failure, and shorter post-operative stays compared to on-pump coronary artery bypass surgery.

Off-pump coronary artery bypass surgery does not reduce gastrointestinal complications.

OBJECTIVES: Gastrointestinal (GI) complications following on-pump coronary artery bypass grafting (CABG) are rare, but carry a high mortality rate. Prolonged cardiopulmonary bypass (CPB) has been associated with a higher incidence of such complications. Little is known about the effect of avoiding CPB on GI complications. Our hypothesis was that off-pump CABG might reduce such complications. METHODS: A total of 2327 consecutive cases undergoing isolated CABG between April 1997 and May 2001 were identified from four consultants' practice at the two cardiothoracic centres involved in this study. We performed a multivariable logistic regression analysis to identify the risk factors for development of post-operative GI complications. Potential risk factors considered in the logistic model were age, sex, angina, ejection fraction, peripheral vascular disease, renal dysfunction, redo operations, previous GI complications, priority of surgery and the use of CPB. RESULTS: A total of 1210 cases were performed on CPB, compared to 1117 off-pump. The incidence of GI complications was 1.2% (n = 14) in the on-pump group and 1.6% (n = 18) in the off-pump group (P = 0.347). The incidence of in-hospital mortality, in the patients who had a GI complication, was 28.6% (n = 4) and 22.2% (n = 4), respectively (P = 0.681). The results of the logistic regression analysis showed that renal dysfunction, advancing age and previous history of GI surgery are significant risk factors for GI complications after coronary bypass surgery whether CPB is used or not. CONCLUSIONS: Our study suggests that off-pump and on-pump techniques are similar in the rates of GI complications. We suggest that a properly designed randomized control trial is needed to verify our findings.

Clopidogrel Within Few Hours of Coronary Artery Bypass Grafting Does Significantly Increase the Risk of Bleeding.

BACKGROUND: Postoperative bleeding after coronary artery surgery is partly related to platelet dysfunction. The aim of this study was to evaluate the effects of a single loading dose of clopidogrel (300 mg) before coronary angiography on bleeding and use of blood and blood products after emergency coronary artery bypass surgery (CABG). METHODS: This is a nonrandomized observational prospective study between January, 2006 till December 2009, at a university hospital, we compare the results of a cohort of 65 patients who received 300 mg clopidogrel during coronary angiography that was followed by emergency CABG (group A or study group) to a cohort of 206 patients who underwent elective coronary artery bypass surgery during the same period by the same surgeons in whom clopidogrel was stopped 7 days before surgery (Group B or control group). Emergency surgery was done because of critical coronary anatomy or because of ongoing chest pain. All patients in the two groups were kept on 100 mg of aspirin until the day of surgery. Outcome data used to compare the two groups, Chest tube drainage in first 12 hours (12 h), need for re-exploration and use of blood and blood product transfusion were prospectively collected. RESULTS: Postoperative bleeding, reoperation rates for bleeding and use of blood products are significantly more in those who received a loading dose of clopedogril within few hours of CABG (group A) compared to those who stopped clopedogril for a week before CABG. CONCLUSIONS: Preoperative 300 mg of clopidogrel is associated with significant increase in post operative bleeding, need for surgical exploration and use of blood and blood product transfusion after CABG.

Which is the best statin for the postoperative coronary artery bypass graft patient?

The progression of atherosclerosis following coronary artery bypass graft (CABG) surgery results in the need for re-vascularisation therapy in a significant proportion of patients. It is well recognised that this risk can be lowered by controlling the level of low-density lipid cholesterol (LDL-C) which can be achieved easily and safely with the use of statins. The choice of which is the best statin in post-CABG patients remains unclear. It has been shown that for milligram-equivalent doses, rosuvastatin provides the greatest LDL-C reduction and greatest number of patients achieving LDL-C targets in comparison with simvastatin and atorvastatin. Rosuvastatin's superiority over other statins in allowing patients to reach LDL-C targets has been maintained in 'real-world' observational studies. Rosuvastatin has also been shown to increase high-density lipid cholesterol (HDL-C) by greater proportions in comparison with other statins, providing increased anti-atherogenic effects. There are several statins currently available, some of which are now generic. However, the empirical use of generic statins does not necessarily translate into a cost-effective treatment option. This article reviews the rationale for lipid-lowering therapy in patients following CABG. We also look objectively at which is the best statin for use in the post-CABG patient, discussing effectiveness, cost and tolerability.

Association of IL6 and IL10 with renal dysfunction and the use of haemofiltration during cardiopulmonary bypass.

OBJECTIVE: Assessment of the effects of haemofiltration during cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG) on the renal function and correlation with interleukin 6 (IL6) and interleukin 10 (IL10) levels. METHODS: Seventy-nine patients scheduled for elective CABG were prospectively randomised into two groups. Group A with a haemofilter attached to arterial line of the CPB circuit and group B without a haemofilter. The two groups were comparable in their symptoms, sex, and previous history of myocardial infarction, left ventricular function, cross-clamp time, bypass time and total grafting per patients. Blood urea and creatinine levels were measured the day before operation, 12h after operation and on the 3rd postoperative day. IL6 and IL10 were measured in blood samples collected 1h before surgery, on arrival to ITU and after 12h. IL6 and IL10 levels were measured using ELISA test. RESULTS: High levels of IL6 (>100 pg/ml) postoperatively were associated with increased incidence of renal dysfunction (p<0.017). Additionally, high IL10 (>30 pg/ml) levels postoperatively were associated with increased incidence of renal dysfunction (p<0.014). There were no effects of the haemofilter on postoperative IL6 and IL10 levels. Use of haemofiltration during CPB was found not to be protective against renal dysfunction (p<0.071). CONCLUSIONS: Haemofilter use during cardiopulmonary bypass does not have a protective effect on postoperative kidney function. Haemofilter has no effect on the level of IL6 and IL10.

Psoriasis-induced postoperative cardiac failure.

Erythroderma-induced cardiogenic shock is a rare but known manifestation of erythrodermic psoriasis. Erythrodermic psoriasis is an aggressive form of the disease and can be precipitated by numerous factors including stress to the body. In this article we present a case of persistent severe vasodilatation after coronary artery bypass surgery that required prolonged epinephrine administration. This was caused by a flareup of erythrodermic psoriasis that was previously only controlled by methotrexate. This drug was omitted in the perioperative phase. Vasodilatation disappeared after treatment was reinstituted.

Does aspirin 6 h after coronary artery bypass grafting optimise graft patency?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether aspirin given 6 h after coronary arterial bypass grafting optimises graft patency. Altogether 201 papers were found using the reported search, of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is good evidence that Aspirin given <6 h post surgery optimally reduces graft occlusion, without an increase in bleeding.

Is there a role for the use of radical lymph node dissection in the surgical management of resectable non-small cell lung cancer?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether there is any survival benefit to the employment of the technique of radical lymph node dissection in the management of operable non-small cell lung cancer (NSCLC). Altogether 305 papers were found using the reported search, of which eight presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that extensive lymph node sampling is of benefit in accurately staging NSCLC, however, the design of studies in the literature has failed to account for the staging effect of extensive lymph node dissection on upstaging cancer patients when trying to determine a survival advantage.