Successful repair of intraoperative aortic dissection detected by transesophageal echocardiography.

Aortic dissection is a rare but devastating complication of cardiac surgery. Early intraoperative diagnosis and management are essential for a favorable outcome. We describe the case of a 69-year-old man with worsening dyspnea who was admitted for mitral valve replacement having previously had a mitral valve repair. Precardiopulmonary bypass transesophageal echocardiography confirmed mitral regurgitation and showed mild atherosclerotic changes in the descending aorta. Following successful replacement of the mitral valve, an attempt to wean from cardiopulmonary bypass failed. This was characterized by acute onset hypovolemia. The transesophageal echocardiography showed the presence of features of acute aortic dissection involving only the descending aorta without identifying the entry point. The tear was successfully repaired by direct suture within the lumen.

Venous thromboembolism in the intensive care unit.

Most ICU patients have a significant number of risk factors for VTE. The high incidence of DVT in the ICU population and the recognition of a high incidence of PE at autopsy confirm this. We have alluded to the difficulty of clinical diagnosis of VTE and the need for diagnostic investigations. We have reviewed currently available diagnostic investigations with regard to their sensitivity and specificity and their practicability in ICU patients, and have formulated recommended diagnostic algorithms (Figs. 4 and 5). The most important factor in the management of VTE is prevention. In the ICU, all patients are at high risk for VTE, and therefore, at a minimum should receive subcutaneous prophylactic heparin unless it is contraindicated. Alternative methods of prophylaxis are available, and should be considered for patients who have contraindications to heparin.

A possible association between aprotinin and improved survival after radical surgery for mesothelioma.

BACKGROUND: Aprotinin has been used to decrease blood loss with complicated cardiac surgery but has not been investigated in extrapleural pneumonectomy, an operation that does not use cardiopulmonary bypass. In this prospective, randomized, placebo-controlled, double-blind trial, the authors investigated whether aprotinin decreased blood loss in patients who underwent this operation. METHODS: After appropriate statistical design and institutional review board approval, eligible patients who were scheduled for extrapleural pneumonectomy were randomized to receive either aprotinin or placebo during the operation. Blood loss and survival data were obtained from electronic medical records and surgical databases. RESULTS: Of 20 patients who were enrolled, 16 patients met criteria for blood loss analysis. Four patients were excluded from the blood loss analysis: Three patients were inoperable because of tumor spread and underwent limited surgery, and 1 patient died intraoperatively because of acute, massive hemorrhage. The mean blood loss was 769 mL with aprotinin versus 1832 mL with placebo (P = .05; Wilcoxon test). All 20 patients were included in survival analyses. All 9 patients who received placebo died. In contrast, 7 of 11 patients who received aprotinin remained alive at the time of the current report. Kaplan-Meier survival curves differed significantly between the 2 groups (P = .0004). A Bayesian multivariate survival analysis of 18 patients who had complete data available on 8 prognostic variables indicated a posterior probability of .99 that aprotinin was beneficial. CONCLUSIONS: Aprotinin decreased blood loss. After accounting for covariate effects, there was a significant comparative benefit with aprotinin in postoperative survival. This finding was unexpected and could not be considered conclusive because of the small size of the current study. A confirmatory study may be warranted.

Coronary revascularization: a procedure in transition from on-pump to off-pump? The role of glucose-insulin-potassium revisited in a randomized, placebo-controlled study.

OBJECTIVE: To investigate an optimized glucose-insulin-potassium (GIK) solution regimen as an alternate myocardial protective strategy in off-pump coronary artery bypass graft (OP-CAB) surgery and as a supplement to conventional coronary artery bypass graft (CABG) surgery using cardiopulmonary bypass (CPB). DESIGN: Prospective, randomized, placebo-controlled. SETTING: Single institution, cardiothoracic specialty hospital. PARTICIPANTS: Forty-four patients scheduled for elective multivessel coronary artery surgery using either conventional CPB (n = 22) or OP-CAB techniques (n = 22). INTERVENTIONS: Preischemic, ischemic, and postischemic administration of GIK solution was carried out, optimally dosed to ensure nonesterified fatty acid (NEFA) suppression, and supplemented with magnesium, a glycolytic enzymatic cofactor. MEASUREMENTS AND MAIN RESULTS: GIK solution therapy reduced plasma NEFA levels (p < 0.001) in OP-CAB surgery and CPB groups but failed to affect the incidence of non-Q wave perioperative myocardial infarction, incidence of postoperative atrial fibrillation, incidence of postoperative infection, reduction in creatinine clearance, or duration of postoperative intensive care unit or hospital length of stay. After adjusting for GIK solution therapy, OP-CAB surgery resulted in significantly less ischemic injury (troponin I >15 microg/L, 19.0% v 91.3%; p = 0.0001) and reduced postoperative infections (14.3% v 43.5%; p = 0.049). CONCLUSION: GIK solution therapy achieved NEFA suppression and an insignificant trend toward reduced biochemical parameters of ischemic injury in OP-CAB surgery and CPB groups, but no major clinical benefit (perioperative myocardial infarction, intensive care unit length of stay, or hospital length of stay) was shown after elective CABG surgery in low-risk patients. Compared with CPB, OP-CAB surgery significantly reduced ischemic injury and postoperative infections.