Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial.

BACKGROUND: Aortic arch surgery has a high incidence of brain injury. This may in part be caused by a cerebral metabolic deficit observed after hypothermic circulatory arrest (HCA). We hypothesized that selective antegrade cerebral perfusion (SACP) would attenuate this phenomenon. METHODS AND RESULTS: In a prospective randomized trial, 42 adult patients were allocated to either HCA (22) or SACP. HCA occurred at a nasopharyngeal temperature of 15 degrees C and SACP at a corporeal temperature of 25 degrees C with cerebral perfusion at 15 degrees C. Paired arterial and jugular venous samples were taken before and after arrest. Continuous transcranial Doppler monitoring of middle cerebral artery velocity (MCAV) was performed. Neuropsychometric testing was performed preoperatively and at 6 and 12 weeks postoperatively. There were 3 hospital deaths (7.1%), 2 strokes (4.8%), and 6 episodes of transient neurological deficit (14.3%). From before to after arrest, jugular bulb pO2 changed by -21.67 mm Hg (26.4) in the HCA group versus +2.27 mm Hg (18.8) in the SACP group (P=0.007). Oxygen extraction changed by +1.7 mL/dL (1.3) in the HCA group versus -1 mL/dL (2.4) in the SACP group (P<0.001). MCAV increased by 6.25 cm/s (9.1) in the HCA group and 19.2 cm/s (10.1) in the SACP group (P=0.001). Incidence of neuropsychometric deficit at 6 weeks was 6/12 (50%) in HCA patients and 8/10 (80%) in SACP patients (P=0.2), and at 12 weeks was 6/16 (38%) in HCA patients and 4/11 (36%) in SACP patients (P=1). CONCLUSIONS: SACP attenuates the metabolic changes seen after HCA. Further studies are required to assess optimal perfusion conditions and clinical outcome.

Hospital morbidity and mortality and changes in quality of life following mitral valve surgery in the elderly.

BACKGROUND AND AIM OF THE STUDY: An increasing number of elderly patients are now requiring mitral valve surgery (MVS). However, due to a perceived increase in risk of morbidity and mortality following cardiac surgery, many elderly patients tend to be neglected or not referred for surgery. METHODS: The outcome of MVS in terms of hospital morbidity and mortality, length of intensive care unit (ICU) and hospital stays, and change in NYHA functional class and quality of life following surgery was assessed in 43 elderly patients (18 males, 25 females; median age 77 years (IQR 75-82 years)) who underwent primary open mitral valve repair (MVRr) or replacement (MVR) between November 1994 and September 1997. Their preoperative clinical characteristics, incidence of hospital morbidity, hospital mortality and length of ICU and hospital stays following MVS were recorded. At follow up, NYHA class was assessed and quality of life parameters monitored using the SF-36 questionnaire. RESULTS: At surgery, 69% of patients were in NYHA class III/IV, 36% underwent non-elective surgery and 44% had symptoms of more than three years' duration. Among patients, 80% presented with mitral incompetence and MVRr was undertaken in 51%. The median bypass and cross-clamp times for MVRr were significantly longer than for MVR. After surgery, 98% of patients required inotropic support, 9% renal dialysis, and 42% ventilatory support for >24 h. In addition, 37% developed respiratory complications, 12% renal failure, 19% needed re-exploration for bleeding, and 5% suffered a stroke. The mean ICU stay after surgery was three days; average in-hospital stay was 10 days. The 30-day mortality rate was 22.7% after MVRr and 38% after MVR. There was a significant improvement in energy, and role limitation due to physical and mental health after MVS. CONCLUSIONS: Elderly patients underwent MVS, usually after a degree of clinical deterioration. Although morbidity and mortality following mitral valve surgery were high, at follow up there was a significant improvement in both symptoms and quality of life of survivors.

Extrapleural bronchial artery ligation for life-threatening hemoptysis in cystic fibrosis--a case report.

Hemoptyses are common in cystic fibrosis (CF) patients. They range from massive life-threatening (> 240 mL/24 hours) to recurrent minor streaking. Limited pulmonary reserve, potential concurrent chest infection, and the progressive nature of CF pose a high risk to this subgroup. Conservative management and selective bronchial artery embolization (BAE) control most acute episodes, but the recurrence rate is high. The possible need for lung transplantation in future makes an extrapleural approach for bronchial artery ligation desirable. The aim of this study was to assess the role of extrapleural bronchial artery ligation in the treatment of recurrent hemoptysis in CF patients. This is a retrospective analysis of four patients between 1986 and 1999 treated by extrapleural thoracotomy and ligation of bronchial arteries. Indications, surgical experience, and outcome are presented. Three patients underwent unilateral, and one patient bilateral extrapleural thoracotomy (in two separate sessions) for bronchial artery ligation. There were three men and one woman, with a mean age of 26.6 years (range 19-32 years). Indications were failure to stabilize the bronchial arterial catheter for BAE (three cases), recurrence after BAE previously controlled bleeding (one case), and communication with the right costocervical trunk signifying risk to the spinal circulation (one case). The mean follow-up was 68 months (range 3-144 months). There was one death in this series, a patient who was asphyxiated with hemoptysis, requiring ventilation preoperatively. He underwent successful extrapleural thoracotomy for bronchial artery ligation, with no further bleeding but succumbed to severe chest infection and multiorgan failure a few days later. Two patients had recurrent bleeding 12 and 36 months after surgery. Selective bronchial angiography proved the contralateral bronchial arteries to be the culprit. Extrapleural bronchial artery ligation is an effective method of controlling hemoptysis in CF, when BAE has failed. This approach minimizes pleural adhesions and is, therefore, desirable in the future consideration for lung transplantation. In this experience, muscle-sparing thoracotomy and postoperative epidural analgesia significantly improved the postoperative recovery.

A survey of patient satisfaction after day case surgery.

A prospective survey of patients attending day case surgery was undertaken to determine patient satisfaction. In an eight-week prospective study, patients undergoing procedures in the day surgical unit were asked to fill in two questionnaires, the first before surgery and the second two weeks after surgery. One hundred and eighty-nine patients were recruited into the study; of these, 98 (52.4%) returned correctly completed forms. Most of the patients believed the information given them before surgery was adequate and the standard of care in the day unit was high. Only five patients needed to see their general practitioner because of continued problems. Twenty-one patients felt they were discharged too early. Our current practice in day case surgery inevitably leads to some patients being discharged early. Facilities must be provided for some patients to stay longer in the day unit. Day case surgery did not result in an unacceptable increase in the workload for GPs, nor did it compromise the quality of patient care.