Tricks and pitfalls regarding the hemodynamics of patients undergoing non-transplantation surgery for heart failure.

This paper aims to address the mechanisms responsible for poor perioperative cardiac performance, analyzing the pathophysiology of heart failure and the main hemodynamic parameters (contractility, preload, afterload, systemic vascular resistance, and pulmonary artery pressure) used in diagnosing patients and assessing their response to therapy. It will also discuss potential therapeutic approaches to cardiac surgery patients. With advances in monitoring and life support, our critically ill patients often become trapped in a sheer, impenetrable net of wires and tubes. Unfortunately, technology can seriously compromise patient safety if the data obtained is misinterpreted. While advanced technology has become a part of daily life in the Intensive Care Unit (ICU), there remains a crucial step that cannot be performed by computers: the link from sensors to patient status. We should always remember to look past the cables and monitors and to look at the patient. This would not only reduce the number of ever-present wires, but would also help improve patient outcome. The field of non-transplant cardiac surgery for heart failure is extremely challenging for the cardiac anesthesiologist. The high incidence of postoperative low cardiac output syndrome should mandate aggressive monitoring and therapy. Nevertheless, a comprehensive understanding of the pathophysiology of heart failure and the hemodynamic implications of surgical therapies is mandatory for optimal patient management. In particular, the presence of systolic dysfunction should not automatically rule out other potential causes of poor global cardiac performance.

The outcome of patients requiring emergency conversion from off-pump to on-pump coronary artery bypass grafting.

BACKGROUND AND OBJECTIVE: Patients undergoing off-pump coronary artery bypass grafting (CABG) may need emergent institution of cardiopulmonary bypass (CPB) for circulatory collapse during the operation. Our aim was to evaluate outcome in such patients and identify preoperative and intraoperative risk factors. METHODS: This is an observational study in a University Hospital setting. In the period June 2001-July 2003, data from 988 consecutive patients undergoing CABG in our institution were prospectively collected. No interventions were made. Prolonged hospital stay (>7 days), hospital mortality, temporal trends and risk factors for conversion from off-pump to on-pump surgery were studied. RESULTS: Fifty-four patients with emergency operations and six with associated carotid artery surgery were excluded. Of the remaining 928 patients, 450 (48.5%) were planned for off-pump surgery. Thirty-seven (8.2%) of them required conversion to CPB on an emergency basis. These patients had higher mortality (5.4%) than the off-pump group (1.5%) and the CPB group (0.4%), P = 0.02. The incidence of prolonged hospital stay was also higher (conversion group = 27%, off-pump group = 12.3%, CPB group = 17.6%; P = 0.02). We did not identify any perioperative characteristics significantly associated with the risk of requiring conversion. The conversion rate was uniformly distributed over the study period. CONCLUSIONS: Patients who are emergently converted to CPB during attempted off-pump procedures are at higher risk of death and prolonged hospital stay; this population should be included in comparative studies as "intention to treat" in the off-pump group.

A propensity score analysis on the effect of eliminating cardiopulmonary bypass for coronary artery bypass grafting.

AIM: The aim of the study was to investigate if the off-pump technique could reduce the hospital mortality after coronary artery bypass grafting when compared to the standard cardiopulmonary bypass (CPB) technique. METHODS: An observational study with propensity score matching analysis was performed in a university teaching hospital in 2,899 consecutive patients undergoing elective coronary artery bypass grafting. No intervention was performed. Major perioperative complications and hospital mortality were noted. RESULTS: The overall hospital mortality was 1.3% (39/2,899) with no difference between the off-pump (16/802, 2.0%) and the CPB group (23/2,097, 1.1%) P=0.09. Since the off-pump group included patients at high risk, a propensity score analysis was then performed and off-pump patients matched 1:1 to CPB patients in order to have the same preoperative variables identified by a multivariate analysis as associated to surgeon propensity to operate off-pump: (age, chronic renal failure and low ejection fraction) and the same number of graft performed. The results of the propensity matching still showed no difference in hospital mortality between off-pump and CPB group (1.6% vs 1.1% P=0.6). The off-pump technique showed advantages in terms of transfusion of blood products (P<0.001) and reduction of surgical re-exploration (P=0.04). CONCLUSIONS: No difference in hospital mortality in coronary artery bypass grafting patients could be observed between patients operated off-pump or with the standard CPB technique.

[Intraoperative radiotherapy: anesthesiologic problems during transport of patients]. / Radioterapia intraoperatoria: problemi anestesiologici durante il trasporto del paziente.

In this study the condition of anesthesia in 8 patients, undergoing intraoperative radiation therapy (IORT) for pancreatic or rectal tumors, is evaluated. Patients with reapproximated surgical incision were transferred from the operating room to the radiotherapy department while still under anesthesia. The risks of such transport as well as guidelines for the patient's care during this phase are examined. The results of this study indicate that in order to move anesthetized patients safely it is necessary to ensure stable cardiovascular, respiratory and metabolic conditions prior to their transfer. It is also important to guarantee adequate analgesia and to establish appropriate monitoring during transport.