Integrating continuous monitoring and evaluation of risk-adjusted outcomes in a cardiac surgical program.

BACKGROUND: The variable life-adjusted display (VLAD) method shows the difference between predicted and observed outcomes over time. Our study aims to implement routine in-house monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery. METHODS: The Society of Thoracic Surgeons (STS) risk score was calculated for 249 isolated and combined coronary and aortic or mitral valve cases performed during a 6-month period. The nine predicted STS variables were operative mortality, permanent stroke, renal failure (RF), prolonged ventilation, deep sternal wound (DSW) infection, reoperation for any reason, short and long length of stay (LOS), and major morbidity or operative mortality. EuroSCORE II was also calculated for the study population. VLAD plots were generated for each variable indicating whether performance is better or worse than expected on the basis of predicted risk of failure. RESULTS: The mortality plot was fluctuating close to baseline risk. The prolonged ventilation, RF, reoperation, morbidity/mortality, and LOS plots were consistently positive, indicating favorable results. The stroke chart showed an upward trend for most of the period until two incidents toward last month led to a steep descent. The DSW infections plot though, indicated a worse-than-expected performance. The VLAD charts were shared in multidisciplinary meetings and clinicians were able to confront the performance with the population-specific expectancies and respond to adverse trends with further actions. CONCLUSION: Graphical tool monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery is feasible and allows detection of underperformance and implementation of changes in clinical practice.

Decreased DNA Disruption in the Porcine Neocortex with Erythromycin Preconditioning during Prolonged Hypothermic Circulatory Arrest: Evidence for Neuroprotection.

BACKGROUND AND AIM OF THE STUDY: We have previously reported that the neocortex is selectively vulnerable to injury in an acute porcine model of hypothermic circulatory arrest (HCA) at 18°C. In view of recent evidence showing that pharmacologic preconditioning with a single dose of erythromycin induces tolerance against transient global cerebral ischemia in rats, we hypothesized that erythromycin would reduce the number of apoptotic neurons in the neocortex in an acute porcine model of HCA at 18°C. METHODS: Fourteen piglets underwent 75 min of HCA at 18°C following pretreatment with erythromycin (25 mg/kg, IV) (n = 8) or vehicle (Normal Saline 0.9%) (n = 6), applied 12 hr before arrest. Three served as normal controls. After gradual rewarming to a temperature of 36°C, treatment animals were sacrificed and brains were perfusion-fixed and cryopreserved. Neuronal apoptosis after HCA was observed morphologically with hematoxylin and eosin staining, and characterized by in situ DNA fragmentation using terminal deoxynucleotidyl-transferase-mediated biotin-dUTP nick end-labeling (TUNEL) histochemistry. RESULTS: Pre-ischemic conditioning with a single dose of the antibiotic erythromycin reduced neuronal apoptosis in the neocortex of the porcine brain. TUNEL-positive cells indicating DNA fragmentation and neuronal injury were significantly greater in the neocortex of animals treated with 18°C HCA (2.55 ± 1.17) compared to animals undergoing HCA after erythromycin preconditioning (1.76 ± 0.91) (p ≤ 0.001). CONCLUSIONS: These results suggest that cerebral protection during HCA may be achieved with erythromycin pharmacological preconditioning in the porcine model.

'Early' post-cardiotomy chylopericardium and the imaging value of magnetic resonance thoracic-ductography.

Isolated chylopericardium is a rare postoperative complication after cardiac surgery. A delay in diagnosis or an inappropriate management can lead to serious consequences. The treatment, which may either be conservative or surgical, is controversial and it depends on the duration and volume of effusion. We report a case of chylopericardium after atrial septal defect repair in a young woman. The patient was treated initially with total parenteral nutrition for 10 days. After drainage diminished, low fat diet containing medium chain triglyceride was instituted. Postoperatively, the role of magnetic resonance thoracic ductography was important for the assessment of the treatment strategy.

Noninvasive ventilation for post-pneumonectomy severe hypoxemia.

ARDS remains a lethal complication after major lung resections. The reported mortality ranges from 50% to 100%, with increased incidence and mortality rates in pneumonectomy patients. The pathogenesis of early ARDS is still not fully understood, and the majority of patients will require mechanical ventilation. A review of the literature reveals that the role of noninvasive ventilation (NIV) in ARDS after lung resection is unclear, in contrast to its well established benefits in other types of respiratory failure. NIV is a technique of augmenting alveolar ventilation delivered by face mask, without introducing an endotracheal tube. NIV may reduce the need for endotracheal mechanical ventilation and improve clinical outcome in patients with acute respiratory failure after lung resection, avoiding complications related to intubation. We present a case of early ARDS following left-sided pneumonectomy, where bi-level positive airway pressure ventilation prompted a successful outcome.

Unligated left internal mammary artery side branch resulting in coronary artery steal syndrome.

Whether internal mammary artery side branches have the potential for hemodynamically significant flow steal in cases of postcoronary surgery ischemia remains a controversial issue. We present a case in which coil embolization of two unligated side branches resulted in symptomatic improvement and resolution of ischemia as evidenced by myoview imaging.

Suicidal hanging donors for lung transplantation: Is this chapter still closed? Midterm experience from a single center in United Kingdom.

In the context of limited donor pool in cardiothoracic transplantation, utilization of organs from high risk donors, such as suicidal hanging donors, while ensuring safety, is under consideration. We sought to evaluate the outcomes of lung transplantations (LTx) that use organs from this group.Between January 2011 and December 2015, 265 LTx were performed at our center. Twenty-two recipients received lungs from donors after suicidal hanging (group 1). The remaining 243 transplantations were used as a control (group 2). Analysis of recipient and donor characteristics as well as outcomes was performed.No statistically significant difference was found in the donor characteristics between analyzed groups, except for higher incidence of cardiac arrest, younger age and smoking history of hanging donors (P < .001, P = .022 and P = .0042, respectively). Recipient preoperative and perioperative characteristics were comparable. Postoperatively in group 1 there was a higher incidence of extracorporeal life support (27.3 vs 9.1%, P = .019). There were no significant differences in chronic lung allograft dysfunction-free survival between group 1 and 2: 92.3 vs 94% at 1 year and 65.9 vs 75.5% at 3 years (P = .99). The estimated cumulative survival rate was also similar between groups: 68.2 vs 83.2% at 1 year and 68.2% versus 72% at 3 years (P = .3758).Hanging as a donor cause of death is not associated with poor mid-term survival or chronic lung allograft dysfunction following transplantation. These results encourage assessment of lungs from hanging donors, and their consideration for transplantation.

Influence of history of cannabis smoking in selected donors on the outcomes of lung transplantation.

OBJECTIVES: Cannabis is the most commonly abused illicit drug and the smokers are at the risk of lung infections, bullous emphysema and lung cancer. However, no evidence about the outcomes of lung transplantation (LTx) utilizing the lungs from such donors is available in the literature. METHODS: We retrospectively analysed lung 'organ offers' and LTx at our centre between January 2007 and November 2013. The outcomes of LTx utilizing lungs from donors with a history of cannabis smoking were compared with the outcomes of those with no such history using unadjusted model as well as propensity score matching. RESULTS: A total of 302 LTxs were performed during this period and were grouped depending on the history of cannabis smoking in donors-'cannabis' (n = 19) and control group (n = 283). All the donors in 'cannabis' group were tobacco smokers compared with 43% in the control group. Preoperative characteristics in recipients in both groups were comparable. Intraoperative and post-LTx variables including 1- and 3-year survivals were comparable in both groups. CONCLUSIONS: The history of donor cannabis smoking does not appear to affect early and mid-term outcomes after LTx and potentially improve the donor pool. As it does not seem to negatively affect the outcomes after LTx, it should not be per se considered a contraindication for lung donation.

Contemporary review of the organ care system in lung transplantation: potential advantages of a portable ex-vivo lung perfusion system.

INTRODUCTION: Lung transplantation remains the definite treatment for various end-stage lung diseases. Cold flush perfusion, the standard method for organ procurement has severe limitations. Organ Care System (OCS; TransMedics, Inc., Andover, USA) is an approved method to preserve hearts for transplantation that allows for greatly reduced cold ischemic time. Consequently, the use of an adapted OCS lung as a portable full ex-vivo lung perfusion system in lung transplantation is currently under close evaluation. Areas covered: The aim of this article is to review the advantages and the role of the OCS in the field of lung transplantation by reviewing the latest literature and evaluating this novel procurement technique in the context of conventional methods like cold flush and regular ex-vivo lung perfusion. Expert commentary: The use of OCS in the field of lung transplantation has great potential for improved patients outcomes and is justified in cases with (i) marginal donor lungs, (ii) foreseeable long time of transportation (iii) high-risk recipient or donor /recipient profiles, particularly in the setting of an overall increasing need for suitable donor organs. Results from two major multi-centre prospective studies are pending to objectively assess the possible advantages of this portable ex-vivo lung perfusion system.

A new pattern for using both thoracic arteries to revascularize the entire heart: the pi-graft.

We present a complex graft for total arterial revascularization based on bilateral skeletonized internal thoracic arteries (ITA). The lower two-thirds of the free right ITA is anastomosed to the proximal segment of the left in situ ITA using the T-graft technique (Tector-Barner-Calafiore). The free, transected distal part of the left ITA is then anastomosed end-to-side on free right ITA (T-on-T anastomosis). In addition, the technique may use another graft extending the proximal third of the in situ right ITA with the free radial artery for right-sided revascularization. The entire operation can be performed off-pump to avoid any procedure on the ascending aorta.

Pericardial fat is strongly associated with atrial fibrillation after coronary artery bypass graft surgery†.

OBJECTIVES: Recent evidence suggests that pericardial fat may represent an important risk factor for cardiovascular disease because of its unique properties and its proximity to cardiac structures. It has been reported that pericardial fat volume (PFV) is associated with atrial fibrillation (AF). The purpose of this study was to investigate the association between PFV and new-onset AF following coronary artery bypass graft surgery (CABG). METHODS: PFV was measured using computed tomography in 83 patients with coronary artery disease scheduled to undergo elective isolated on-pump CABG. Patient characteristics, medical history and perioperative variables were prospectively collected. Any documented episode of new-onset postoperative AF until discharge was defined as the study end point. RESULTS: Twenty-eight patients (33.7%) developed postoperatively AF during hospital stay. There was no significant difference in demographics and comorbidities among patients that maintained sinus rhythm (SR) and their AF counterparts. In univariate analysis, patients with postoperative AF had significantly more pericardial fat compared with SR patients (195 ± 80 ml vs 126 ± 47 ml, P = 0.0001). Larger left atrial diameter was also associated with postoperative AF (42.4 ± 6.9 mm vs 39.3 ± 4.8 mm, P = 0.017). Additionally, the prebypass use of calcium channel-blocking agents was independently associated with a lower incidence of postoperative AF, confirmed also by multivariate analysis (P = 0.035). In multivariate logistic regression analysis, PFV was the strongest independent variable associated with the development of postoperative AF (odds ratio: 1.018, 95% confidence interval: 1.009-1.027, P = 0.0001). The best discriminant value assessed by receiver operating characteristic analysis was 129.5 ml (sensitivity 86% and specificity 56%). CONCLUSIONS: PFV is strongly associated with AF following CABG, independently of many traditional risk factors. Our findings suggest that PFV may represent a novel risk factor for postoperative AF. However, the role of pericardial fat in AF mechanism needs to be further delineated.

Atypical pattern of lung involvement in pacemaker endocarditis.

Pacemaker endocarditis has a high rate of morbidity and mortality and is associated with substantial health-care cost. To maximize the effectiveness of treatment, diagnosis of pacemaker endocarditis should be made as early as possible. Medical treatment alone is not successful, and the removal of the entire artificial pacing system is often required. We present a case of a female patient with a permanent transvenous pacemaker, recurring episodes of fever and chills, general malaise, and a computed tomography image of a solitary tumor-like lesion indicating pneumonia. The symptoms subsided with empirical antibiotics but without improvement in the radiologic images. A wedge resection of the lesion by thoracotomy was performed, revealing a necrotic lung lesion compatible with pulmonary infarct. Transesophageal echocardiography showed a mass that was adherent to the pacemaker lead. The therapeutic approach consisted of surgical removal of the complete pacing system along with long-term antibiotic therapy and implantation of a new device with an epicardial lead. Serial follow-up echocardiograms for a 1-y period did not show any recurrence, and the subsequent course was uneventful.

Aortic root aneurysm in an adult patient with aortic coarctation: a single-stage approach.

Coarctation of the aorta is a common congenital defect that may be undiagnosed until adulthood. Moreover, coarctation is associated with congenital and acquired cardiac pathology that may require surgical intervention. The management of an adult patient with aortic coarctation and an associated cardiac defect poses a great technical challenge since there are no standard guidelines for the therapy of such a complex pathology. Several extra-anatomic bypass grafting techniques have been described, including methods in which distal anastomosis is performed on the descending thoracic aorta, allowing simultaneous intracardiac repair. We report here a 37-year old man who was diagnosed with an aortic root aneurysm and aortic coarctation. The patient was treated electively with a single-stage approach through a median sternotomy that consisted of valve-sparing replacement of the aortic root and ascending-to-descending extra-anatomic aortic bypass, using a 18-mm Dacron graft. Firstly, the aortic root was replaced with the Yacoub remodelling procedure, and then the distal anastomosis was performed to the descending aorta, behind the heart, with the posterior pericardial approach. The extra-anatomic bypass graft was brought laterally from the right atrium and implanted in the ascending graft. Postoperative recovery was uneventful and a control computed tomographic angiogram 1 month after complete repair showed good results.

The role of ascorbic acid in the prevention of atrial fibrillation after elective on-pump myocardial revascularization surgery: a single-center experience--a pilot study.

Atrial fibrillation (AF) is a common arrhythmia that occurs postoperatively in cardiac surgery. There is evidence for the role of oxidative stress in the etiology of AF. In our study, we examined whether antioxidant ascorbic acid (vitamin C), could help in the reduction of the incidence of postoperative AF. Patients who were scheduled to undergo elective isolated on-pump coronary artery bypass grafting (CABG) were included in our study. One hundred and seventy patients were randomly divided in two groups: Group A (n=85) received vitamin C preoperatively and postoperatively whereas Group B (n=85) did not receive any (control group). The incidence of AF was 44.7% in the vitamin C group and 61.2% in the control group (P=0.041). The hospitalization time, the intensive care unit stay and the time interval for the conversion of AF into sinus rhythm was significantly shorter in the vitamin C group. Patients that developed AF also had longer hospital length of stay (9.5±2.8 days vs. 6.7±1.9, P=0.034). Supplementation of vitamin C reduces the incidence of postCABG AF, and decreases the time needed for rhythm restoration and length of hospital stay.

Local iodine pleurodesis versus thoracoscopic talc insufflation in recurrent malignant pleural effusion: a prospective randomized control trial.

OBJECTIVE: To compare the efficacy, safety, and outcome of thoracoscopic talc poudrage (TTP) versus povidone-iodine pleurodesis (PIP) through a thoracostomy tube as a palliative treatment of pleural effusion due to metastatic breast carcinoma (MBC). METHODS: A total of 42 MBC patients were prospectively enrolled in a randomized controlled trial. Twenty-two patients received TTP (group A), whereas 20 patients (group B) underwent pleurodesis by instilling povidone-iodine through a thoracostomy tube, as a bedside procedure. RESULTS: The mean age was 48.2 ± 9.9 (range: 29-64) years and 50.2 ± 7 (range: 32-62) years for groups A and B, respectively (p=ns). At presentation, all patients had moderate to severe dyspnea, New York Heart Association (NYHA)>II and Medical Research Council (MRC) dyspnea scale 3-5. Morbidity in both groups was low. Post-procedure analgesic requirements due to severe pleuritic chest pain were higher in group A (18% vs 0%, p=0.2). Four patients in group A (18%) and one in group B (5%) were febrile (>38°C) within 48 h of the procedure. Both groups achieved good symptom control, with improvement in MRC dyspnea scale (1-3). There were no in-hospital deaths. Post-procedure hospital stay was lower in group B (p=0.009). The mean progression-free interval was 6.6 (range 3-15) months. At follow-up (mean: 22.6 (range: 8-48) months), recurrence of significant pleural effusion requiring intervention was noted in two and three patients in group A and group B, respectively (p=ns). CONCLUSION: Povidone-iodine can be considered as a good alternative to TTP to ensure effective pleurodesis for patients with malignant pleural effusion due to MBC. The drug is available, cost effective and safe, can be given through a thoracostomy tube and can be repeated if necessary.

Operative stabilization of skeletal chest injuries secondary to cardiopulmonary resuscitation in a cardiac surgical patient.

Chest injury, including sternal and rib fractures, is the most common complication of cardiopulmonary resuscitation (CPR) that usually heals spontaneously. However, a small subset of patients has fractures that need mechanical treatment. We present a case of flail chest with sternum and left anterior rib fractures secondary to CPR in a cardiac surgical patient, which was mechanically ventilated due to respiratory complications. Open reduction and operative fixation with titanium osteosynthesis plates and locking screws in sternum and ribs was performed by a thoracic surgeon assisted by an orthopaedic surgeon. Anterior plating achieved chest stability and facilitated weaning from mechanical ventilation. The patient had an uneventful postoperative course, painfree, and experienced no sternal instability or infection throughout a six-month follow-up period. Sternal instability after cardiac surgery occurs infrequently but can be challenging to manage. Titanium plate fixation is an effective method to stabilize complicated flail chest, with clinical utility in a cardiothoracic practice.

Endovascular repair of traumatic aortic transection.

The present study reports a single center experience and mid-term results of endovascular repair of acute aortic traumatic transection on an emergency basis, instead of open surgical management. From January 2005 to December 2008, 13 cases of traumatic aortic transection with serious comorbidities, which underwent repair with thoracic stent grafts at our institution, were reviewed. The mean patient age was 32.5+/-7.8 years. During the follow-up period of 25.5+/-12.8 months, 12 patients were alive and one patient died of associated injuries. There were no intraoperative deaths, no incidence of paraplegia and no procedure-related mortality. The blood loses during the procedure were minimal. The thoracic aortic grafts were larger than the thoracic aorta by 12.4+/-5.7%. Five cases required complete or partial coverage of the left subclavian artery. There were two cases of graft collapse, which were successfully treated by endovascular reintervention. Our results suggest that this approach is safe, effective and can be performed with low rates of morbidity and mortality, especially in respect of patients with multiple injuries. Although initial results are encouraging, close long-term follow-up and technical improvements of the stent grafts are required.

Hypothermia at 10 degrees C reduces neurologic injury after hypothermic circulatory arrest in the pig.

BACKGROUND: We have previously reported that sensory, motor neocortex, and hippocampus are selectively vulnerable to injury in an acute porcine model of HCA at 18 degrees C. This study was undertaken to assess whether further cooling to 10 degrees C can reduce neurological injury during HCA. METHODS: Twelve piglets underwent 75 minutes of HCA at 18 degrees C (n = 6) and 10 degrees C (n = 6). Four served as normal controls. After gradual rewarming and 80 minutes of reperfusion, treatment animals were sacrificed and brains were perfusion-fixed and cryopreserved. Regional patterns of neuronal apoptosis after HCA were characterized by in situ DNA fragmentation using TUNEL histochemistry. Hematoxylin and eosin histology was used to characterize cell damage morphologically. TUNEL-positive cells were scored on a scale of 0 to 5. Grade 0: no TUNEL-positive cells; Grade 1: < 10%; Grade 2: 10% to 25%, Grade 3: 25% to 50%, Grade 4: 50% to 75%; and Grade 5: > 75%. RESULTS: TUNEL-positive cells indicating DNA fragmentation were scored in the motor and sensory neocortex, hippocampus, cerebellum, thalamus, and medulla of animals treated with 18 degrees C and 10 degrees C HCA and were significantly greater than in normal controls. Profound cooling to 10 degrees C resulted in a significant reduction of neuronal injury in the neocortex and hippocampus. CONCLUSIONS: This data support that cerebral protection may be better at very cold temperatures compared to 18 degrees C hypothermia. Regions selectively vulnerable to neuronal injury are offered more neural protection by profound hypothermia. These affects are observed in the acute state, suggesting activation of the apoptotic mechanisms at early stages can be inhibited by profound hypothermia.

Effect of profound hypothermia during circulatory arrest on neurologic injury and apoptotic repressor protein Bcl-2 expression in an acute porcine model.

OBJECTIVES: We reported that the neocortex and hippocampus are selectively vulnerable to injury in an acute porcine model of hypothermic circulatory arrest at 18 degrees C. We hypothesize that further cooling to 10 degrees C could reduce neurologic injury in these regions. To further elucidate the mechanisms of neurologic injury and protection, we assessed the expression of the anti-apoptotic protein Bcl-2. METHODS: Twelve piglets underwent 75 minutes of hypothermic circulatory arrest at 18 degrees C (n = 6) and 10 degrees C (n = 6). After gradual rewarming and reperfusion, animals were put to death and brains were perfusion-fixed and cryopreserved. Regional patterns of neuronal apoptosis after hypothermic circulatory arrest were characterized by in situ DNA fragmentation with terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) histochemistry. Bcl-2 protein expression was characterized with immunohistochemistry. Statistical comparisons were made by t test, analysis of variance, and Mann-Whitney U test, as appropriate. RESULTS: Concentrations of TUNEL(+) cells were significantly lower after profound hypothermia at 10 degrees C compared with 18 degrees C hypothermia in the sensory and motor neocortex and hippocampus (t test, P < .0001; P < .006; P < .006, respectively). Positive Bcl-2 immunostaining was observed only in the motor and sensory neocortex and hippocampus after 18 degrees C hypothermic circulatory arrest. Profound cooling to 10 degrees C resulted in a significant increase in Bcl-2 immunostaining in the motor and sensory cortex as compared with 18 degrees C (Mann-Whitney U test, P < .05). CONCLUSIONS: Deep hypothermia at 10 degrees C protects the neocortex and hippocampus from insult during hypothermic circulatory arrest as suggested by significantly reduced TUNEL(+) staining in these areas. Although a concomitant increase in Bcl-2 expression was observed in the neocortex at 10 degrees C, it remains unclear whether profound hypothermia deters from neuronal injury by activation of the anti-apoptotic protein Bcl-2.