Eficacia y seguridad del aterótomo vascular pacientes adultos con enfermedad arterial periférica supra e infrapoplítea que no sean elegibles para bypass quirúrgico / Efficacy and safety of vascular atherotomy in adult patients with supra and infrapopliteal peripheral arterial disease who are not eligible for surgical bypass

INTRODUCCIÓN: El presente dictamen preliminar expone la evaluación de la eficacia y seguridad del aterótomo vascular en pacientes adultos con enfermedad arterial periférica (PAD, por sus siglas en inglés) supra e infra poplítea, que no sean elegibles para bypass quirúrgico. La enfermedad arterial periférica se caracteriza por afectar la circulación extra cardiaca y extra craneal generando síntomas como la claudicación, dolor al reposo, y hasta isquemia crítica. Esto limita el flujo sanguíneo a las extremidades debido al depósito de grasa en las arterias, y a la formación de placas cálcicas afectando la calidad de vida de los pacientes. El manejo de la enfermedad arterial periférica comienza desde el control de los estilos de vida, y de los factores de riesgo (hipertensión y diabetes mellitus, principalmente), llegando hasta el tratamiento invasivo, el cual puede consistir en bypass quirúrgico, tratamiento endovascular (angioplastia percutánea transluminal, stents, o aterectomía), o el uso concomitante de estas terapias. Actualmente en EsSalud, se viene manejando a los pacientes con bypass quirúrgico, stents o angioplastia. La decisión de seleccionar la terapia específica depende básicamente de las características del paciente, de la severidad de las lesiones endovasculares, así como de la experiencia del médico asistente. - Los médicos especialistas postulan que el aterótomo vascular, podría constituirse en una alternativa viable para el tratamiento de la enfermedad arterial periférica supra e infra poplítea en pacientes no elegibles para bypass quirúrgico, dado que el beneficio teórico refiere una reducción de las placas cálcicas, que permite una remodelación vascular, una reducción en la presión arterial, y permitir el uso posterior de la angioplastia. METODOLOGÍA: El presente documento es la producción de un dictamen preliminar basado en la síntesis y evaluación de la evidencia disponible a la fecha (setiembre 2020) más relevante al contexto de EsSalud. La evidencia incluida en este dictamen preliminar se encuentra organizada de acuerdo a la pirámide de jerarquía de la evidencia de Haynes (Dicenso, Bayley, and Haynes 2009) de tal manera que la evidencia con mayor nivel metodológico es presentada en primer lugar. Por lo tanto, se han priorizado la inclusión de estudios en este orden: guía de práctica clínica (GPC), evaluaciones de tecnologías sanitarias, revisiones sistemáticas con metaanálisis y ensayo clínico aleatorizado (ECA). No se fijaron restricciones de idioma ni localización geográfica. Se han excluido revisiones narrativas de la literatura, reportes o serie de casos, editoriales, opiniones de expertos, cartas al editor e informes técnicos de casas comerciales. Se realizó una búsqueda bibliográfica abierta en las bases de datos PubMed, Cochrane Database, y TripDataBase (material suplementario). La búsqueda sistemática fue suplementada con una búsqueda manual de páginas de las diferentes sociedades médicas, y la lista de referencias bibliográficas de los estudios seleccionados, a fin de identificar otras publicaciones de relevancia que pudiesen haber sido omitidos por la estrategia de búsqueda. RESULTADOS: De la búsqueda bibliográfica sistemática se identificaron estudios inicialmente, de los cuales fueron elegibles para tamizaje por título y resumen. Se obtuvieron estudios elegibles para evaluación a texto completo, de los cuales fue considerado elegible para inclusión en el presente documento (Figura N ° 01). Las principales razones de exclusión fueron población e intervención no acorde con la pregunta PICO. De la búsqueda manual se recabaron estudios elegibles para inclusión en el presente documento. Como producto de la búsqueda bibliográfica, se ha incluido una GPC, dos revisiones sistémicas y metaanálisis, dos ECA, y tres estudios observacionales que responden a la pregunta PICO. CONCLUSIONES: El presente dictamen expone un análisis de la mejor evidencia disponible a la fecha (setiembre 2020) respecto a la eficacia y seguridad del aterótomo vascular para el tratamiento de pacientes adultos con diagnóstico de la enfermedad arterial periférica supra e infra poplítea que no sean elegibles para bypass quirúrgico. La enfermedad arterial periférica se caracteriza por afectar la circulación extra cardiaca y extra craneal, generando síntomas como la claudicación, dolor al reposo, y hasta isquemia crítica, por lo que imponen una carga negativa sobre la calidad de vida de los pacientes. En la actualidad existen diferentes alternativas de tratamiento, los cuales inicialmente se basan en cambios en el estilo de vida, así como el uso de medicamentos para controlar los factores de riesgo, como son la hipertensión arterial y la diabetes mellitus. Con respecto al tratamiento invasivo, este puede consistir en bypass quirúrgico, tratamiento endovascular (angioplastia percutánea translimitar, stents, o aterectomía), o el uso concomitante de estas terapias. Actualmente en EsSalud, se viene manejando a los pacientes con bypass quirúrgico, stents o angioplastia. La decisión de emplear una terapia depende básicamente de las características del paciente, de la severidad de las lesiones endovasculares, así como de la preferencia del médico asistente. En consecuencia, los médicos especialistas del Servicio De Radiología General e Intervencionista del Hospital Nacional Guillermo Almenara Irigoyen han solicitado al IETSI la evaluación del aterótomo vascular como alternativa terapéutica para pacientes que no son elegibles para bypass quirúrgico, en comparación con la angioplastia. Como producto de una búsqueda bibliográfica y un proceso de selección de la evidencia, se ha incluido una GPC, tres revisiones sistemáticas y metaanálisis, dos ECA y tres estudios observacionales que respondieran la pregunta PICO. Una de las GPC menciona entre sus recomendaciones al uso de angioplastia, y no de aterectomía dado que no ha podido demostrar algún beneficio clínicamente relevante, además de representar un incremento en el costo del tratamiento. Una de las revisiones sistemáticas incluidas en el presente documento reportó un incremento en la mortalidad en el grupo que recibió aterectomía, sin embargo, también reportó una heterogeneidad moderada entre los dos estudios incluidos, además de reportar deficiencias en la metodología de dichos estudios. Mientras que las otras dos revisiones sistemáticas no reportaron diferencias estadísticamente significativas en los desenlaces de mortalidad, amputación, o complicaciones. Los ECA incluidos reportan que no existe un beneficio clínicamente relevante con el uso concomitante de aterectomía con angioplastia, y, por el contrario, podría representar un incremento en el riesgo de presentar eventos adversos. Así, el ECA piloto de Dattilo et al., 2014 reportó un incremento en la supervivencia a la revascularización a los seis meses, sin embargo, esta diferencia no se mantuvo al año de seguimiento. Es así como, la comparación a largo plazo entre angioplastia y aterectomía con angioplastia resultó no ser estadísticamente diferente. Mientras que el ECA de Shammas et al., 2011 reportó que no haber diferencias en la revascularización de la lesión objetivo, en la tasa de revascularización del vaso objetivo, la amputación del MMII, ni en la mortalidad, entre los dos grupos de estudio. Sin embargo, sí se reportó un incremento en la macroembolización distal en el grupo de aterectomía, que, a pesar de no presentar secuelas por el uso de filtros, requiere de mayor estudio para determinar si puede incrementar los eventos adversos. Con respecto a los estudios observacionales, el estudio de Zia et al., 2019 reportó mayor riesgo de ser reintervenido a los 48 meses de seguimiento, así como de presentar complicaciones locales al año de seguimiento, principalmente hematomas y embolización distal, en el grupo de at/ PTA, en comparación con el grupo PTA. Asimismo, el estudio de Ramkumar et al., 2019, incluyendo más de 16 mil sujetos de estudio, provenientes de 500 centros, seguidos por hasta cinco años, reporta que el uso de aterectomía incrementa el riesgo de presentar amputación, en comparación con PTA. Por otro lado, el estudio de Todd et al., 2013 reporta que la inclusión de aterectomía dentro del manejo de PAD no ha reportado alguna diferencia relevante en reducir la mortalidad, brindar alivio sintomático, reducir complicaciones o evitar reintervenciones, en comparación con PTA durante el seguimiento de tres años. Así, el cuerpo de evidencia aquí presentado indica que el uso de aterectomía con o sin angioplastia no es mejor que sólo angioplastia para el tratamiento de la enfermedad arterial periférica. Además, se hace evidente una incertidumbre acerca de la seguridad de esta tecnología, debido a la mala calidad de los estudios que no tienen el suficiente poder para poder afirmar si realmente no existe diferencias estadísticamente significativas entre aterectomía y angioplastia. Por lo tanto, debido a la incertidumbre acerca de la existencia de un beneficio clínico y a costo de, a la fecha y con la evidencia científica disponible al momento, no es posible asumir un perfil de costo-oportunidad favorable para el contexto de EsSalud. Por lo expuesto, el IETSI no aprueba el uso del aterótomo vascular para el tratamiento de pacientes adultos con diagnóstico de enfermedad arterial periférica supra e infra poplítea que no sean elegibles para bypass quirúrgico.

Eficacia y seguridad de óxido nítrico en pacientes pediátricos con hipertensión pulmonar severa para uso perioperatorio de cirugía cardiovascular / Efficacy and safety of nitric oxide in pediatric patients with severe pulmonary hypertension for perioperative use of cardiovascular surgery

INTRODUCCIÓN: El presente dictamen expone la evaluación de tecnología de la eficacia y seguridad de óxido nítrico inhalado, para el tratamiento de pacientes con hipertensión pulmonar severa en estadio perioperatorio y postoperatorio de cirugía cardiovascular. La hipertensión pulmonar (HP) es una enfermedad con un pobre pronóstico en la población pediátrica con una incidencia de 3 a 20 casos por millón de niños por año según datos internacionales. No se cuenta con datos peruanos sobre su incidencia o prevalencia. En muchos casos pediátricos, existe una anomalía congénita cardiovascular de fondo que conlleva a presentar HP. Durante el periodo perioperatorio (antes, durante y después de la cirugía) para la reparación quirúrgica de estas anomalías cardiovasculares existe el riesgo de presentar una crisis hipertensiva pulmonar que según algunos estudios tiene un riesgo de mortalidad de aproximadamente de 20 por ciento. La HP se caracteriza por presentar una elevada presión a nivel de los vasos pulmonares que conlleva a cambios estructurales que obstruyen y dificultan que la sangre bombeada del corazón -específicamente desde el ventrículo derecho-a los pulmones llegue en su totalidad. Esto a su vez desencadena en una falla cardiaca derecha que repercute luego en una falla cardiaca izquierda para finalmente presentarse una falla cardiaca terminal que en la mayoría de casos solo podrá ser resuelta con un trasplante de corazón. No existe un consenso universal sobre la definición de severidad de la HP. Sin embargo, en muchos casos se evalúa tal severidad de acuerdo a una adaptación de la clasificación de falla cardiaca según la Organización Mundial de la Salud (OMS). Utilizando esta herramienta, se dice que a mayor severidad de HP el paciente presenta mayores signos y síntomas de falla cardiaca y mayor limitación para realizar actividades cotidianas. El manejo convencional de la HP incluye el uso de oxígeno, diuréticos, agentes inotrópicos como la digoxina para el manejo de falla cardiaca derecha, el uso de sedantes, relajantes musculares y el uso de anticoagulantes como warfarina en casos muy específicos. METODOLOGÍA: Para responder la pregunta PICO de investigación (Tabla 6) se realizó una búsqueda bibliográfica sistemática abierta en las bases de datos MEDLINE vía PubMed, Cochrane Database (ambas estrategias de búsqueda en el Material Suplementario) y www.clinicaltrials.gov. Adicionalmente se realizó una búsqueda manual de guías de práctica clínica y evaluaciones de tecnologías sanitarias en las páginas web de: Scottish Intercollegiate Guidelines Network (SIGN), National Institute for Health and Care Excellence (NICE), Canadian Agency for Drugs and Technologies in Health (CADTH), Scottish Medicines Consortium (SMC),Institute for Clinical and Economic Review (ICER), Agency for Health Research and Quality (AHRQ), Guidelines International Network (G-I-N), New Zeland Guidelines Group (NZGG), Red de Evaluación de Tecnologías en Salud de las Américas (RedETSA), y Base Regional de Informes de Evaluaciones de Tecnologías en Salud de las Américas (BRISA). Por último, se revisaron las sociedades especializadas en hipertensión pulmonar como la American College of Cardiology Foundation (ACCF), la American Heart Association (AHA), la European Respiratory Society (ERS) y la American Thoracic Society (ATS). RESULTADOS: Se describe la evidencia disponible de acuerdo al tipo de publicación encontrada. CONCLUSIONES: El presente dictamen tuvo como objetivo evaluar la mejor evidencia científica disponible hasta marzo del 2020 en relación a la eficacia y seguridad del uso de óxido nítrico inhalado en paciente menor de 14 años con hipertensión pulmonar severa durante el periodo perioperatorio de una cirugía cardiovascular. La hipertensión pulmonar es una enfermedad a nivel de los vasos pulmonares de pobre pronóstico. Esta enfermedad puede presentarse como una complicación durante el periodo perioperatorio una crisis aguda de hipertensión pulmonar que de no ser tratada conlleva a un alto riesgo de mortalidad (20 %) y al probable uso de una tecnología invasiva, riesgosa y costosa como el ECMO. El óxido nítrico administrado por vía inhalatoria a una dosis máxima diaria de 20 ppm produce la activación de la guanilato ciclasa que produce una reacción en cadena para finalmente relajar los músculos de los vasos pulmonares (vasodilatación) y disminuir de esta manera la hipertensión pulmonar. La evidencia proveniente de dos GPC y un ECA sugiere, de manera conjunta, que el uso de iNO durante el periodo perioperatorio de una cirugía cardiovascular puede ser de beneficio clínico para el paciente tanto para disminuir el riesgo como para tratar la crisis hipertensiva pulmonar, una complicación severa y de alta mortalidad de la hipertensión pulmonar. Por lo expuesto, el IETSI aprueba el uso de óxido nítrico inhalatorio por vía endotraqueal para el manejo de los pacientes menores de 14 años que presentan hipertensión pulmonar severa durante el periodo postoperatorio de una cirugía cardiovascular, según lo establecido en el Anexo N° 1. La vigencia del presente dictamen preliminar es de un año a partir de la fecha de publicación y está sujeta a la evaluación de los resultados obtenidos y de nueva evidencia que pueda surgir en el tiempo.

A functional assessment of the circle of Willis before aortic arch surgery using transcranial Doppler.

BACKGROUND: Antegrade selective cerebral perfusion (ASCP) with systemic moderate hypothermia is routinely used as brain protection during aortic arch surgery. Whether ASCP should be delivered unilaterally (u-ASCP) or bilaterally (bi-ASCP) remains controversial. METHODS: We routinely studied the functional anatomy of the circle of Willis (CoW in all patients scheduled for arch surgery using transcranial color-coded Doppler over a decade. On the basis of these data, we classified observed functional variants as being "safe," "moderately safe," or "unsafe" for u-ASCP. RESULTS: From January 2005 to June 2015, 1119 patients underwent aortic arch surgery in our institution. Of these, 636 patients had elective surgery performed with ASCP. Preoperative full functional assessment of the CoW was possible in 61% of patients. A functionally complete CoW was found in only 27%. Of all variants, 72% were classified as being safe for u-ASCP, whereas 18% were moderately safe for u-ASCP, and 10% unsafe. Unsafe variants for bi-ASCP were observed in 0.5% of patients. CONCLUSIONS: The risk of ischemic brain damage due to malperfusion is estimated to be substantially higher during right u-ASCP than during bi-ASCP. Bi-ASCP is therefore highly preferable over u-ASCP if the function of the CoW is unknown. We propose a tailored approach using this full functional assessment preoperatively by applying u-ASCP via the right subclavian artery when considered safely possible, and bi-ASCP when considered a necessity to prevent cerebral malperfusion, and thus thereby try to reduce the embolic stroke risk of ostial instrumentation in bi-ASCP.

Emergências cardiológicas: avaliação nutricional - parte I / Cardiological emergences: nutritional assessment - Part I

As emergências cardiológicas podem causar rápidas e profundas alterações na resposta metabólica e sistêmica. Essas alterações contribuem acentuadamente para a mobilização das reservas corporais que repercutirão no estado nutricional. A avaliação nutricional, ainda que não seja realizada na fase crítica da assistência interdisciplinar, deverá ser realizada o quanto antes, visando a adoção da alimentação adequada e reposição hídrica e de eletrólitos. O uso de ferramentas subjetivas capazes de estimar o risco nutricional global é de fácil aplicação devido a sua praticidade e rapidez. Entre essas destaca-se o Nutritional Risk Score ­ NRS 2002. Sempre que possível, a avaliação nutricional global deve ser complementada pela avaliação nutricional objetiva e pelo uso de marcadores nutricionais bioquímicos, os quais auxiliarão na avaliação mais precisa do estado nutricional do paciente crítico. Essas ferramentas devem ser utilizadas por nutricionistas treinados e os resultados devem ser discutidos pela equipe multidisciplinar de terapia nutricional que decidirá as estratégias mais adequadas para o início da terapia nutricional precoce nos quadros de emergências cardiológicas

Cardiac emergencies can cause rapid and profound changes in the metabolic and systemic response. These changes contribute significantly to the mobilization of body reserves, which will affect nutritional status. Nutritional evaluation, although not performed in the critical phase of interdisciplinary care, should be carried out as early as possible in order to ensure an adequate diet, and water and electrolyte replacement. The use of subjective tools capable of estimating the global nutritional risk is easy to apply due to its effective and rapid application. One such tool is the Nutritional Risk Score ­ NRS 2002. Whenever possible, the global nutritional assessment should be complemented with objective nutritional assessment and the use of biochemical nutritional markers, which will help obtain a more accurate evaluation of the nutritional status of the critically ill patient. These tools should be applied by trained nutritionists, and the results should be discussed by the multidisciplinary nutritional therapy team, which will decide on the most appropriate strategies for the initiation of early nutritional therapy in cardiac emergency situations

A Pilot Assessment of 3 Point-of-Care Strategies for Diagnosis of Perioperative Lung Pathology.

BACKGROUND: Lung ultrasonography is superior to clinical examination and chest X-ray (CXR) in diagnosis of acute respiratory pathology in the emergency and critical care setting and after cardiothoracic surgery in intensive care. Lung ultrasound may be useful before cardiothoracic surgery and after discharge from intensive care, but the proportion of significant respiratory pathology in this setting is unknown and may be too low to justify its routine use. The aim of this study was to determine the proportion of clinically significant respiratory pathology detectable with CXR, clinical examination, and lung ultrasound in patients on the ward before and after cardiothoracic surgery. METHODS: In this prospective observational study, patients undergoing elective cardiothoracic surgery who received a CXR as part of standard care preoperatively or after discharge from the intensive care unit received a standardized clinical assessment and then a lung ultrasound examination within 24 hours of the CXR by 2 clinicians. The incidence of collapse/atelectasis, consolidation, alveolar-interstitial syndrome, pleural effusion, and pneumothorax were compared between clinical examination, CXR, and lung ultrasound (reference method) based on predefined diagnostic criteria in 3 zones of each lung. RESULTS: In 78 participants included, presence of any pathology was detected in 56% of the cohort by lung ultrasound; 24% preoperatively and 94% postoperatively. With lung ultrasound as a reference, the sensitivity of the 5 different pathologies ranged from 7% to 69% (CXR), 7% to 76% (clinical examination), and 14% to 94% (combined); the specificity of the 5 different pathologies ranged from 91% to 98% (CXR), from 90% to 99% (clinical examination), and from 82% to 97% (combined). For clinical examination and lung ultrasound, intraobserver agreements beyond chance ranged from 0.28 to 0.70 and from 0.84 to 0.97, respectively. The agreements beyond chance of pathologic diagnoses between modalities ranged from 0.11 to 0.64 (CXR and lung ultrasound), from 0.08 to 0.7 (CXR and lung ultrasound), and from 0 to 0.58 (clinical examination and CXR). CONCLUSIONS: Clinically important respiratory pathology is detectable by lung ultrasound in a substantial number of noncritically ill, pre or postoperative cardiothoracic surgery participants with high estimate of interobserver agreement beyond that expected by chance, and we showed clinically significant diagnoses may be missed by the contemporary practice of clinical examination and CXR.

Point-of-care-based protocol with first-line therapy with coagulation factor concentrates is associated with decrease allogenic blood transfusion and costs in cardiovascular surgery: an Italian single-center experience.

BACKGROUND: Transfusion in patients having cardiac surgery has been associated with increased morbidity, mortality, and costs. This analysis assessed the impact of a rotational thromboelastometry (ROTEM®)- and functional platelet assessment (Multiplate®)-based protocol for bleeding management on perioperative outcomes and costs in patients undergoing cardiac surgery. METHODS: This retrospective analysis of the records of all patients who underwent cardiac surgery at the Hesperia Hospital, Modena, Italy, from December 2012 to December 2013 compared outcomes and costs of bleeding management for the two 6-month periods before/after introduction of the ROTEM- and Multiplate-based protocol. Descriptive and correlation analysis were performed as appropriate. Propensity score matching and its correlation analysis were performed. RESULTS: Data from 768 consecutive patients (mean age ~69 years, ~66% male) were included; 50.7% and 49.3% of patients had surgery before and after protocol introduction, respectively. Significantly fewer patients required transfusions of packed red blood cells after the protocol introduction over the 24 hours postsurgery (100 vs. 197 patients; P<0.001) and during ICU stay (134 vs. 221 patients; P<0.001). A significantly greater proportion of patients treated after protocol introduction received prothrombin complex concentrate (31 vs. 16; P<0.05) and fibrinogen concentrate (36 vs. 13; P<0.001). A significantly greater proportion of patients treated after protocol introduction had an ICU stay duration <48 hours (81.5% vs. 71.5%; P<0.001). ROTEM-based bleeding management was associated with a saving of €128,676.23 for the 379 patients undergoing surgery post-protocol introduction (€339.52 per patient). CONCLUSIONS: ROTEM-guided bleeding management in patients undergoing cardiac surgery was cost-effective and associated with an increase of administration of coagulation factor concentrates and a decrease of ICU length of stay.

Advances in aortic disease management: a year in review.

PURPOSE OF REVIEW: The medical and surgical management of aortic disease is continually changing in search for improved outcomes. Our objective is to highlight recent advances in a few select areas pertaining to aortic disease and aortic surgery: the genetics of aortopathy, medical therapy of aortic aneurysms, advances in cardiac imaging, and operative strategies for the aortic arch. RECENT FINDINGS: As our understanding of the genetic basis for aortopathy continues to improve, routine genetic testing may be of value in assessing patients with genetically triggered forms of aortic disease. With regard to medical advances, treating patients with Marfan syndrome with either losartan or atenolol at an earlier stage in their disease course improves outcomes. In addition, novel imaging indices such as wall shear stress and aortic stiffness assessed by MRI may become useful markers of aortopathy and warrant further study. With regard to the optimal technique for cerebral perfusion in aortic arch surgery, high-quality data are still lacking. Finally, in patients with complex, multilevel aortic disease, the frozen elephant trunk is a viable single-stage option compared with the conventional elephant trunk, although with an increased risk for spinal cord injury. SUMMARY: Based on recent advances, continued studies in genetics, cardiac imaging, and surgical trials will further elucidate the etiology of aortopathy and ultimately guide management, both medically and surgically.

An ex-vivo quantitative assessment to determine the optimal aortotomy closure technique.

BACKGROUND: After performing an aortotomy, there are a variety of techniques utilized for suture closure. There is no published data comparing the efficacy of various suture techniques. The goal of this study is to provide an ex-vivo quantitative assessment of resistance to leakage and dehiscence for three aortotomy closure techniques. MATERIALS AND METHODS: An ex-vivo model was developed utilizing explanted porcine aorta. Aortotomies were closed using one of three techniques: 1) single layer baseball stitch 2) double layer baseball stitch 3) horizontal mattress stitch with a top layer baseball stitch. The aorta was pressurized with saline using an apparatus which captured all leaked fluid. The intra-aortic pressure was adjusted over 8 increments from 110 to 375 mmHg. Leakage rates were determined at each pressure level. Ten aortotomies were performed for each technique, resulting in 240 calculated leakage rates. RESULTS: At all pressures, the horizontal mattress group was measured to have significantly less leakage when compared to single or double layer baseball stitch closures (p < 0.005). There was a trend towards a lower leakage rate in the double layer baseball compared to the single layer baseball stitch. However, this difference is statistically significant only at 300 and 335 mmHg. There were no instances of rupture. CONCLUSION: This study provides the first quantitative comparison of three commonly used aortotomy closure techniques. The running horizontal mattress stitch combined with a baseball stitch provides the greatest resistance to leakage at all pressures. This technique may be superior in clinical scenarios with challenging hemostasis.

Reduction in hospital costs and resource consumption associated with the use of advanced topical hemostats during inpatient procedures.

OBJECTIVE: The use of hemostatic agents has increased over time for all surgical procedures. The purpose of this study was to evaluate the newer topical absorbable hemostat products Surgicel * Fibrillar † and Surgicel SNoW ‡ (Surgicel advanced products, abbreviated as SAPs) compared to the older product Surgicel Original (SO) with respect to healthcare resource use and costs in procedures where these hemostats are most commonly used. RESEARCH DESIGN AND METHODS: A retrospective analysis of the Premier hospital database was used to identify adults who underwent brain/cerebral (BC), cardiovascular (CV: valve surgery and coronary artery bypass graft) and carotid endarterectomy (CEA) between January 2011-December 2012. Among these patients, those treated with SAPs were compared to those treated with SO. Propensity score matching (PSM) was used to create comparable groups to evaluate differences between SAPs and SO. MAIN OUTCOME MEASURES: The primary end-points for this study were length of stay (LOS), all-cause total cost, number of intensive care unit (ICU) days, ICU cost, transfusion costs and units, and SO/SAP product units per discharge. RESULTS: Matched PSM created patient cohorts for SO and SAPs were created for BC (n = 758 for both groups), CV (n = 3388 for both groups), and CEA (n = 2041 for both groups) procedures. Patients that received SAPs had a 14-16% lower mean LOS for each procedure compared to SO, as well as 12-18% lower total mean cost per discharge for each procedure (p < 0.02 for all results). Mean ICU costs for SAPs were also lower, with a reduction of 20% for BC and 19% for CV compared to SO (p < 0.01). However, for CEA, there was no statistically significant difference in ICU costs for SAPs compared to SO. CONCLUSIONS: In a retrospective hospital database analysis, the use of SAPs were associated with lower healthcare resource utilization and costs compared to SO.

Feasibility of near real-time lesion assessment during radiofrequency catheter ablation in humans using acoustic radiation force impulse imaging.

BACKGROUND: Visual confirmation of radiofrequency ablation (RFA) lesions during clinical cardiac ablation procedures could improve procedure efficacy, safety, and efficiency. It was previously shown that acoustic radiation force impulse (ARFI) imaging can identify RFA lesions in vitro and in vivo in an animal model. This is the "first-in-human" feasibility demonstration of intracardiac ARFI imaging of RFA lesions in patients undergoing catheter ablation for atrial flutter (AFL) or atrial fibrillation (AF). METHODS AND RESULTS: Patients scheduled for right atrial (RA) ablation for AFL or left atrial (LA) ablation for drug refractory AF were eligible for imaging. Diastole-gated intracardiac ARFI images were acquired using one of two equipment configurations: (1) a Siemens ACUSON S2000™ ultrasound scanner and 8/10Fr AcuNav™ ultrasound catheter, or (2) a CARTO 3™ integrated Siemens SC2000™ and 10Fr SoundStar™ ultrasound catheter. A total of 11 patients (AFL = 3; AF = 8) were imaged. ARFI images were acquired of ablation target regions, including the RA cavotricuspid isthmus (CTI), and the LA roof, pulmonary vein ostia, posterior wall, posterior mitral valve annulus, and the ridge between the pulmonary vein and LA appendage. ARFI images revealed increased relative myocardial stiffness at ablation catheter contact sites after RFA and at anatomical mapping-tagged RFA treatment sites. CONCLUSIONS: ARFI images from a pilot group of patients undergoing catheter ablation for AFL and AF demonstrate the ability of this technique to identify intra-procedure RFA lesion formation. The results encourage further refinement of ARFI imaging clinical tools and continued investigation in larger clinical trials.

Transcatheter closure of patent ductus arteriosus and atrial septal defect without on-site surgical backup: a two-year experience in an African community.

Congenital heart disease contributes significantly to the health burden of children in Nigeria. Interventions for congenital heart disease have been available in the developed world since the first report on device closure of patent ductus arteriosus (PDA) in 1967 by Porstmann. However, this did not start in Nigeria until October 2010. This study aimed to document the profiles of the patients who had undergone interventions for congenital heart diseases since the availability of the procedure, the challenges encountered, and the prospects associated with the interventions at the study site. All the patients referred to undergo interventions for congenital heart disease at the study center between October 2010 and 2012 were studied. The profile of the patient, including diagnosis at referral, indication for interventions, and interventions performed, were documented. The patients ranged in age from 3 to 62 years (mean age, 13.54 ± 17.7 years), and the male-to-female ratio was 1:3. The diagnosis at referral included PDA in 10 (83 %) of the 12 patients and secundum atrial septal defect in 2 patients (17 %). They all had transcatheter closure of the defects. Interventional procedures for congenital heart diseases currently are available locally, but the high degree of manpower training required, the cost, and the local availability of consumables are major factors limiting their use. Regional and international collaboration could be mutually beneficial.

Preoperative assessment of coronary arteries in patients undergoing thoraco-abdominal and noncoronary cardiovascular surgery with dual-source computed tomography angiography.

AIMS: To retrospectively evaluate coronary anomalies and coronary wall atheromatous changes by using dual-source computed tomography angiography (DSCTA) for preoperative assessment of patients with thoraco-abdominal and noncoronary cardiovascular disease. MATERIALS AND METHODS: One hundred and eighty-one patients scheduled for elective noncoronary cardiovascular surgery (heart valve disease group, HVD; arrhythmia group, Arrhy; or aortic aneurysm group, AA) underwent a DSCTA examination for preoperative preparation. Anomalous origin of coronary arteries, myocardial bridge (MB), coronary wall atheromatous changes, luminal stenosis, and types of plaques were evaluated and compared among the three groups. RESULTS: Anomalous origin of coronary arteries and MB were observed in 5.1% and 21.5% of patients. Anomalous origin of the coronary artery from the opposite sinus was most common (55.6%). MB was most frequently detected in the distal segment of the left anterior descending artery (LAD) (1.2%). Plaques were most common in the proximal segment of the LAD (16.4%) and LAD branches (42.2%). Diseased vessels and segments were more common in AA group, followed by Arrhy patients and finally HVD groups (p < 0.001 for each group). Multivessel involvement and significant stenosis of AA group were significantly more common than the other two groups. Noncalcified plaque and all grades of stenosis were more common in AA patients. CONCLUSION: DSCTA is useful for preoperative assessment of coronary arteries in patients undergoing thoraco-abdominal and noncoronary cardiovascular surgery. DSCTA detected higher prevalence of coronary artery disease in AA patients than in the other two groups of patients.

Role of multidetector CT in assessment of repaired tetralogy of Fallot.

The population of adults with repaired tetralogy of Fallot (TOF) is growing, thanks to improvements in the surgical and medical management of this condition. Accordingly, late postrepair complications are important medical concerns in these individuals. Initial surgical repair of TOF typically occurs in infancy, consisting of patch repair of the ventricular septal defect (VSD) and relief of right ventricular outflow tract (RVOT) obstruction. Although patients may remain asymptomatic for several decades, the majority will have progressive pulmonic regurgitation that leads to right ventricular (RV) dilatation and functional deterioration. Other frequently seen complications include branch pulmonary artery stenosis, RVOT aneurysms, and recurrent VSDs. Cardiac computed tomography (CT) is widely available and, in some cases, is the imaging modality of choice for serial evaluation of TOF patients. CT is particularly useful when magnetic resonance (MR) imaging is contraindicated (eg, in patients with implantable cardiac devices). Unlike MR imaging, cardiac CT allows excellent visualization of endovascular stents and stent-mounted valves. Retrospective electrocardiographically gated cardiac CT can be used for accurate volumetric and functional analysis of the RV. Comprehensive serial evaluation will assist in determining the need for surgical pulmonary valve repair in the setting of progressive RV dysfunction. Three-dimensional volumetric images are useful for evaluation of stent integrity and aneurysm formation. The radiologist should be familiar with the anatomy of TOF, surgical interventions for repair, and postrepair complications encountered at follow-up imaging of these patients. By extracting the breadth of information obtained with cardiac multidetector CT, the radiologist can play an essential role in the management of adult patients with repaired TOF.

Perioperative statin therapy.

INTRODUCTION: The lipid lowering class of drugs known as "Statins" are being increasing recognized for their pleiotropic effects which include anti-inflammation, antioxidant, vasodilatation, improved endothelial function and stabilization of atherosclerotic plaques. These effects may counteract, to some extent, the deleterious impact of surgical stress on various organ systems during the perioperative period. AREAS COVERED: A literature review was undertaken to examine current evidence for the effect of perioperative statin use on postoperative morbidity and mortality. A search of PubMed, Medline and Scopus databases was performed using a combination of search terms including statins and perioperative risk reduction, outcomes, morbidity and mortality. Further searches were made on specific areas such as statins and thrombosis, kidney injury, renal protection, cancer, cost and safety. EXPERT OPINION: Current evidence supports a reduction in cardiovascular morbidity and mortality associated with perioperative statin use in high risk patients undergoing non cardiac surgery and this represents a very cost effective application of statin therapy with few adverse events reported. Data is emerging that point to other benefits such as renal protection but this requires further confirmation from prospective studies. Future research needs to address the questions of the optimal type, timing and dosage of statin therapy as well as whether there are problems associated with abrupt withdrawal and adverse effects associated with long term use.

Assessment of the effect on blood loss and transfusion requirements when adding a polyethylene glycol sealant to the anastomotic closure of aortic procedures: a case-control analysis of 102 patients undergoing Bentall procedures.

BACKGROUND: The use of CoSeal(®), a polyethylene glycol sealant, in cardiac and vascular surgery for prevention of anastomotic bleeding has been subject to prior investigations. We analysed our perioperative data to determine the clinical benefit of using polyethylene glycol sealant to inhibit suture line bleeding in aortic surgery. METHODS: From January 2004 to June 2006, 124 patients underwent aortic surgical procedures such as full root replacements, reconstruction and/or replacement of ascending aorta and aortic arch procedures. A Bentall procedure was employed in 102 of these patients. In 48 of these, a polyethylene glycol sealant was added to the anastomotic closure of the aortic procedure (sealant group) and the other 54 patients did not have this additive treatment to the suture line (control group). RESULTS: There were no significant between-group differences in the demographic characteristics of the patients undergoing Bentall procedures. Mean EuroSCORES (European System for Cardiac Operative Risk Evaluation) were 13.7 ± 7.7 (sealant group) and 14.4 ± 6.2 (control group), p = NS. The polyethylene glycol sealant group had reduced intraoperative and postoperative transfusion requirements (red blood cells: 761 ± 863 versus 1248 ± 1206 ml, p = 0.02; fresh frozen plasma: 413 ± 532 versus 779 ± 834 ml, p = 0.009); and less postoperative drainage loss (985 ± 972 versus 1709 ± 1302 ml, p = 0.002). A trend towards a lower rate of rethoracotomy was observed in the sealant group (1/48 versus 6/54, p = 0.07) and there was significantly less time spent in the intensive care unit or hospital (both p = 0.03). Based on hypothesis-generating calculations, the resulting economic benefit conferred by shorter intensive care unit and hospital stays, reduced transfusion requirements and a potentially lower rethoracotomy rate is estimated at €1,943 per patient in this data analysis. CONCLUSIONS: The use of this polymeric surgical sealant demonstrated improved intraoperative and postoperative management of anastomotic bleeding in Bentall procedures, leading to reduced postoperative drainage loss, less transfusion requirements, and a trend towards a lower rate of rethoracotomy. Hypothesis-generating calculations indicate that the use of this sealant translates to cost savings. Further studies are warranted to investigate the clinical and economic benefits of CoSeal in a prospective manner.

Perspective on coronary interventions & cardiac surgeries in India.

Cardiovascular disease has become the leading cause of morbidity and mortality in India during the last 3 decades. The genetic predisposition and acquisition of traditional risk factors at a rapid rate as a result of urbanization seems to be the major cause. While efforts are being made to contain this epidemic by educating public and applying preventive measures, the ever increasing burden of patients with symptomatic and life threatening manifestations of the disease is posing a major challenge. This requires a concerted effort to develop modern facilities to treat these patients. The healthcare facilities to manage these high risk patients by contemporary methods like percutaneous coronary revascularization and surgical methods have shown a very promising trend during the last decade. The facilities of modern diagnostic methods and new proven techniques to offer symptomatic relief and improve their prognosis are available in most parts of the country. The lack of social security and health insurance for the large majority of the population, however, is a serious limitation. Unregulated availability of some of the newer devices for these techniques had become a very concerning issue. However, in the last few years serious efforts have been made to streamline these procedures. Indigenous research and scientific data acquisition in relation to the modern technology for achieving coronary revascularization has also started on a promising note.

[Strategies of preoperative evaluation and risk reduction in patients undergoing invasive procedures in the view of recent European Society of Cardiology guidelines]. / Strategie oceny przedoperacyjnej i redukcji ryzyka u chorych obciazonych kardiologicznie poddawanych procedurom zabiegowym w ssietle nowych wytycznych Europejskiego Towarzystwa Kardiologicznego.

In this article we summarise recent European Society of Cardiology guidelines on perioperative evaluation and management of patients undergoing invasive non-cardiac procedures. Close attention is paid to pharmacological methods of risk reduction including beta-blockers, statins, aspirin and angiotensin converting enzyme inhibitors. Simple, stepwise and evidence-based algorithm for patient evaluation is presented. We discuss the need for excessive diagnostic tests and coronary revascularisation before the procedure. Time frame for stopping dual antiplatelet therapy following percutaneous coronary interventions, methods of glycaemic control and bridging protocol for patients on oral anticoagulants are also provided. We emphasise the importance of prompt implementation of the above guidelines as the number of surgical procedures being performed in high risk patients (including the elderly) constantly rises.