Survey of the clinical assessment and utility of near-infrared cerebral oximetry in cardiac surgery.

OBJECTIVES: Near-infrared cerebral oximetry increasingly is used for monitoring during cardiac surgery. Nonetheless, the scientific basis for incorporating this technology into clinical practice, the indications for when to do so, and standard diagnostic and treatment algorithms for defining abnormal values are yet to be rigorously defined. The authors hypothesized that there would be (1) variation in clinical use and practices for near-infrared spectroscopy (NIRS), and (2) variation in management of patients when clinicians are provided with NIRS information. In order to test this hypothesis, they sought to assess the nature and strength of response heterogeneity among anesthesiologists and cardiac perfusionists when provided with cardiac surgery patient scenarios and cerebral oximetry data. DESIGN: A prospectively collected survey. SETTING: A hospital-based, multi-institutional, multinational study. PARTICIPANTS: By e-mail, the authors surveyed the membership of the Society of Cardiovascular Anesthesiologists and the online Cardiovascular Perfusion Forum. INTERVENTIONS: This survey was focused on ascertaining what actions clinicians would take in each scenario, given case information and cerebral oximetry tracings. Questions were based on 11 patient scenarios selected to represent small, large, symmetric, or asymmetric decreases in measured regional cerebral oxygen saturation (rScO2) encountered during cardiac surgery. Information on the respondents' (n = 796; 73% anesthesiologists) clinical practice, demography, and cerebral oximetry utilization was collected. An index of dispersion was used to assess response heterogeneity overall and within demographic subgroups. MEASUREMENTS AND MAIN RESULTS: The majority of respondents indicated that cerebral oximetry monitoring was either useful or an essential monitor, especially perfusionists and clinicians who used cerebral oximetry most frequently. There were marked differences in responses between perfusionists and anesthesiologists for 4 of the 6 scenarios (p<0.005 for each of these 4 scenarios) occurring during cardiopulmonary bypass. Scenarios having greatest rScO2 reduction or asymmetry in rScO2 were associated with the highest dispersion, indicating least agreement in management. Scenarios with mild or moderate rScO2 reduction were associated with the lowest dispersion, indicating greater agreement in management. CONCLUSIONS: Although experimental data gradually are accumulating to support the role for cerebral oximetry monitoring during cardiac surgery, the results of the present survey support the view that its role remains poorly defined, and consensus for its appropriate use is lacking. Importantly, the authors observed marked variation in the use, perceived utility, and management of patients for 4 of the 6 CPB scenarios between perfusionists and anesthesiologists who share the management of CPB. These findings support the need for well-designed, adequately-powered clinical trials examining the value of this technology.

Replacement of the quadricuspid aortic valve: strategy to avoid complete heart block.

Quadricuspid aortic valves are rarely encountered by the cardiac surgeon during aortic valve replacement. The most common location for the supranumerary cusp is between the noncoronary and the right coronary cusp, located over the membranous septum, which can potentially increase the risk of complete heart block after valve replacement. We present three quadricuspid aortic valve replacements, one of which was complicated by complete heart block postoperatively. We suggest a strategy to possibly avoid this complication.

Early results of a comprehensive operative and perfusion strategy to attenuate the incidence of adverse neurological outcomes in on-pump coronary artery bypass grafting (CABG) patients.

Adverse neurological events, both focal (Type I) and non-focal (Type II), have been appreciated in postoperative on-pump coronary artery bypass grafting (CABG) patients for many years. Advanced age is a significant risk factor for adverse neurological events following CABG surgery. With full knowledge that our elderly population of patients was at high risk for these untoward neurological events, we adopted a comprehensive operative and perfusion strategy in an attempt to attenuate the incidence of these complications. Our strategy included efforts to minimise the number of emboli generated during the operation, avoid cerebral hypoperfusion, and attenuate the systemic inflammatory response. From 15 August 2002 to 31 December 2005, we performed 355 on-pump CABG operations. The incidence of Type I focal injury was 0/355 (0%), the incidence of Type II non-focal injury was 9/355 (2.5%), and postoperative mortality was 2/355 (0.6%). These results compared favorably to the results predicted by the Society of Thoracic Surgeons' (STS) model, and may suggest efficacy.

Therapeutic efficacy and safety of red blood cells treated with a chemical process (S-303) for pathogen inactivation: a Phase III clinical trial in cardiac surgery patients.

BACKGROUND: A randomized, double-blind trial is reported of the clinical efficacy of red blood cells (RBCs) treated for pathogen inactivation with S-303, a synthetic labile alkylating agent. STUDY DESIGN AND METHODS: Patients undergoing complex cardiac surgeries were randomly assigned to receive either S-303-treated (test) or conventional (control) RBC transfusion during surgery and for 6 days thereafter. Efficacy was evaluated by comparing the occurrence of a composite primary endpoint of treatment-related morbidity (myocardial infarction and renal failure) and mortality. RESULTS: Two-hundred twenty-three patients were randomly assigned and 148 patients who received transfusions (74 with S-303-treated RBCs and 74 with control RBCs) were evaluable. The incidence of the primary endpoint was equivalent between the two groups (22 and 21% in the S-303-treated and control RBC groups, respectively). Secondary endpoints, including hemoglobin increment (mean, 1.4 vs. 1.5 g/dL), number of RBC transfusions (mean, 4.4 vs. 3.8 units), and other blood product support, were also comparable. The adverse event profile was similar between groups; however, patients who received S-303 RBCs were significantly more likely to develop constipation and less likely to suffer supraventricular extrasystoles. Four patients (2 test and 2 control) demonstrated positive indirect antiglobulin tests with reactivity for S-303 RBCs at one or more time points before or after transfusion, without evidence of hemolysis. CONCLUSION: S-303-treated and conventional RBCs were equivalent with respect to clinical efficacy and safety in supporting the transfusion needs of cardiac surgery patients. Investigations are under way to ascertain the significance of S-303 RBC antibodies and to prevent their occurrence.

Early and late results of isolated and combined heart valve surgery in patients > or =80 years of age.

We present a series of 405 consecutive patients aged > or =80 years who underwent isolated or combined valve surgery over a 5-year period. Our results demonstrate that valve surgery in the elderly can be performed with acceptable early mortality, good late survival, and excellent late functional outcome.

Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach.

OBJECTIVES: This study retrospectively reviews an aggressive multidisciplinary approach to the treatment of massive pulmonary embolism, centering on rapid diagnosis with contrast-enhanced computed tomography of the chest to define the location and degree of clot burden and transthoracic echocardiography to document right ventricular strain followed by immediate surgical intervention when appropriate. METHODS: Between October 1999 through February 2004, 47 patients (30 men and 17 women; median age, 58 years; age range, 24-86 years) underwent emergency surgical embolectomy for massive central pulmonary embolism. The indications for surgical intervention were (1) contraindications to thrombolysis (21/47 [45%]), (2) failed medical treatment (5/47 [10%]), and (3) right ventricular dysfunction (15/47 [32%]). Preoperatively, 12 (26%) of 47 patients were in cardiogenic shock, and 6 (11%) of 47 were in cardiac arrest. RESULTS: There were 3 (6%) operative deaths, 2 with preoperative cardiac arrest; 2 of these 3 patients required a right ventricular assist device. In 38 (81%) patients a caval filter was placed intraoperatively. Median length of stay was 11 days (range, 3-75 days). Median follow-up was 27 months (range, 2-50 months); follow-up was 100% complete in surviving patients. There were 6 (12%) late deaths, 5 of which were from metastatic cancer. Actuarial survival at 1 and 3 years' follow-up was 86% and 83%, respectively. CONCLUSION: An aggressive approach to large pulmonary embolus, including rapid diagnosis and prompt surgical intervention, has improved results with surgical embolectomy. We now perform surgical pulmonary embolectomy not only in patients with large central clot burden and hemodynamic compromise but also in hemodynamically stable patients with right ventricular dysfunction documented by means of echocardiography.

Impact of concomitant coronary artery bypass grafting on hospital survival after aortic root replacement.

BACKGROUND: We examined the impact of concomitant coronary artery bypass grafting (CABG) on hospital survival after aortic root replacement. We sought to determine whether CABG procedures that were not originally planned but rather added after the aortic root procedure was completed (CABG/bailout) skewed the results to shift patients with bad outcomes to the CABG group, making the non-CABG group appear undeservedly low risk. METHODS: Between May 1992 and January 2001, 369 consecutive patients underwent aortic root replacement. Concomitant CABG was required in 95 patients (26%). Indications for CABG were significant coronary artery disease in 73 patients (20%), active endocarditis or acute aortic dissection involving the coronary orifices in 14 patients (4%), and difficulty weaning from bypass because of regional wall motion abnormality from presumed but unconfirmed coronary artery disease or technical error at coronary ostial reimplantation (CABG/bailout) in 8 patients (2%). RESULTS: Operative mortality for the entire cohort was 5.7% (21 patients). The operative mortality rate for the non-CABG group was 0.4% (1 of 274 patients), and for the CABG group, 21% (20 of 95 patients; p < 0.001). Independent predictors of operative mortality in the CABG group were New York Heart Association functional class III or IV (odds ratio, 3.9; 95% confidence interval, 1.07 to 14.5), active endocarditis (odds ratio, 9.2; 95% confidence interval, 2.06 to 41.5), acute aortic dissection (odds ratio, 7.6; 95% confidence interval, 1.81 to 32.0), and failure to use retrograde cardioplegia (odds ratio, 6.4; 95% confidence interval, 1.06 to 38.8). The use of CABG/bailout was not a predictor. CONCLUSIONS: Adding CABG at the end of an aortic root procedure is a rare event, and because it is rare, there is no significant shift of risk as a result of the CABG/bailout patients on the overall CABG group.

Left anterior descending coronary endarterectomy: early and late results in 196 consecutive patients.

BACKGROUND: With advances in percutaneous coronary interventions, many patients now referred for coronary artery bypass grafting have diffuse coronary artery disease. We undertook this retrospective study to determine whether left anterior descending (LAD) coronary endarterectomy is a safe and effective long-term adjunct to coronary artery bypass grafting in patients who cannot otherwise be completely revascularized. METHODS: Between January 1992 and March 2000, 196 of 7,633 (2.5%) consecutive patients underwent LAD coronary endarterectomy with coronary artery bypass grafting. Median age was 67 years (range, 33 to 97 years), 101 patients (52%) had unstable angina, and 182 (93%) were in New York Heart Association class III or IV. Thirty-three patients (17%) had ongoing myocardial infarction; another 17 (9%) had myocardial infarction less than 1 month. Thirty patients (15%) required intraaortic balloon pump preoperatively and 19 (10%) were reoperations. RESULTS: All patients underwent LAD endarterectomy with coronary artery bypass grafting to the LAD. The left internal mammary artery was grafted to the LAD in 151 patients (77%), and 46 of 151 (30%) of these required an additional vein patch to the endarterectomized bed. Concomitant valve procedures were performed in 8 (4%) patients. Overall hospital mortality was 3% (6 of 196). Perioperative myocardial infarction in the LAD territory was 3%. One-year survival was 94% (95% confidence interval, 90% to 97%), whereas 5-year survival was 74% (95% confidence interval, 66% to 80%). Freedom from cardiac events (angina, myocardial infarction, congestive heart failure, percutaneous coronary interventions) was 90% (95% confidence interval, 84% to 94%) at 1 year and 84% (95% confidence interval, 75% to 90%) at 5 years. CONCLUSIONS: Despite the presence of diffuse coronary artery disease, coronary artery bypass grafting with LAD endarterectomy offers excellent results with very low hospital mortality and morbidity, and favorable long-term survival.