Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant Pleural Effusion: The TIME1 Randomized Clinical Trial.

IMPORTANCE: For treatment of malignant pleural effusion, nonsteroidal anti-inflammatory drugs (NSAIDs) are avoided because they may reduce pleurodesis efficacy. Smaller chest tubes may be less painful than larger tubes, but efficacy in pleurodesis has not been proven. OBJECTIVE: To assess the effect of chest tube size and analgesia (NSAIDs vs opiates) on pain and clinical efficacy related to pleurodesis in patients with malignant pleural effusion. DESIGN, SETTING, AND PARTICIPANTS: A 2×2 factorial phase 3 randomized clinical trial among 320 patients requiring pleurodesis in 16 UK hospitals from 2007 to 2013. INTERVENTIONS: Patients undergoing thoracoscopy (n = 206; clinical decision if biopsy was required) received a 24F chest tube and were randomized to receive opiates (n = 103) vs NSAIDs (n = 103), and those not undergoing thoracoscopy (n = 114) were randomized to 1 of 4 groups (24F chest tube and opioids [n = 28]; 24F chest tube and NSAIDs [n = 29]; 12F chest tube and opioids [n = 29]; or 12F chest tube and NSAIDs [n = 28]). MAIN OUTCOMES AND MEASURES: Pain while chest tube was in place (0- to 100-mm visual analog scale [VAS] 4 times/d; superiority comparison) and pleurodesis efficacy at 3 months (failure defined as need for further pleural intervention; noninferiority comparison; margin, 15%). RESULTS: Pain scores in the opiate group (n = 150) vs the NSAID group (n = 144) were not significantly different (mean VAS score, 23.8 mm vs 22.1 mm; adjusted difference, -1.5 mm; 95% CI, -5.0 to 2.0 mm; P = .40), but the NSAID group required more rescue analgesia (26.3% vs 38.1%; rate ratio, 2.1; 95% CI, 1.3-3.4; P = .003). Pleurodesis failure occurred in 30 patients (20%) in the opiate group and 33 (23%) in the NSAID group, meeting criteria for noninferiority (difference, -3%; 1-sided 95% CI, -10% to ∞; P = .004 for noninferiority). Pain scores were lower among patients in the 12F chest tube group (n = 54) vs the 24F group (n = 56) (mean VAS score, 22.0 mm vs 26.8 mm; adjusted difference, -6.0 mm; 95% CI, -11.7 to -0.2 mm; P = .04) and 12F chest tubes vs 24F chest tubes were associated with higher pleurodesis failure (30% vs 24%), failing to meet noninferiority criteria (difference, -6%; 1-sided 95% CI, -20% to ∞; P = .14 for noninferiority). Complications during chest tube insertion occurred more commonly with 12F tubes (14% vs 24%; odds ratio, 1.91; P = .20). CONCLUSIONS AND RELEVANCE: Use of NSAIDs vs opiates resulted in no significant difference in pain scores but was associated with more rescue medication. NSAID use resulted in noninferior rates of pleurodesis efficacy at 3 months. Placement of 12F chest tubes vs 24F chest tubes was associated with a statistically significant but clinically modest reduction in pain but failed to meet noninferiority criteria for pleurodesis efficacy. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN33288337.

Duplicated common femoral artery can be safely cannulated for femorofemoral cardiopulmonary bypass.

The duplicated common femoral artery can be safely cannulated for femorofemoral bypass, but we recommend postoperative imaging to identify potential complications. We found no previous reports of duplicated common femoral artery.

Leukodepletion for patients undergoing heart valve surgery.

BACKGROUND: There is some evidence for the benefits of leukodepletion in patients undergoing coronary artery surgery. Its effectiveness in higher risk patients, such as those undergoing heart valve surgery, particularly in terms of overall clinical outcomes, is currently unclear. OBJECTIVES: To assess the beneficial and harmful effects of leukodepletion on clinical, patient-reported and economic outcomes in patients undergoing heart valve surgery. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 3 of 12) in The Cochrane Library, the NHS Economic Evaluations Database (1960 to April 2013), MEDLINE Ovid (1946 to April week 2 2013), EMBASE Ovid (1947 to Week 15 2013), CINAHL (1982 to April 2013) and Web of Science (1970 to 17 April 2013) on 19 April 2013. We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), the US National Institutes of Health (NIH) clinical trials database and the International Standard Randomised Controlled Trial Number Register (ISRCTN) in April 2013 for ongoing studies. No language or time period restrictions were applied. We examined the reference lists of all included randomised controlled trials and contacted authors of identified trials. We searched the 'grey' literature at OpenGrey and handsearched relevant conference proceedings. SELECTION CRITERIA: Randomised controlled trials comparing a leukocyte-depleting arterial line filter with a standard arterial line filter, on the arterial outflow of the heart-lung bypass circuit, in elective patients undergoing heart valve surgery. DATA COLLECTION AND ANALYSIS: Data were collected on the study characteristics, three primary outcomes (1. post-operative in-hospital all-cause mortality within three months, 2. post-operative all-cause mortality excluding inpatient mortality < 30 days, 3. length of stay in hospital, 4. adverse events and serious adverse events) and seven secondary outcomes (1. tubular or glomerular kidney injury, 2. validated health-related quality of life scales, 3. validated renal injury scales, 4. use of continuous veno-venous haemo-filtration, 5. length of stay in intensive care, 6. costs of care). Data were extracted by one author and verified by a second author. Insufficient data were available to perform a meta-analysis or sensitivity analysis. MAIN RESULTS: Eight studies were eligible for inclusion in the review but data on prespecified review outcomes were available from only one, modestly powered (24 participants) study (Hurst 1997). There were no differences between a leuko-depleting versus standard filter in length of stay in the intensive care unit (ICU) (mean difference (MD) 0.80 days; 95% confidence interval (CI) -0.24 to 1.84) or length of hospital stay (MD 0.20 days; 95% CI -1.78 to 2.18). AUTHORS' CONCLUSIONS: There are currently insufficient good quality trials with valve surgery patients to inform recommendations for changes in clinical practice. A future National Institute for Health Research (NIHR)-funded feasibility study (recruiting mid-year 2013) comparing leukodepletion with a standard arterial line filter in patients undergoing elective heart valve surgery (the ROLO trial) will be the largest study to date and will make a significant contribution to future updates of this review.

A surgical strategy for cor triatriatum atrial septal defect--A1 lam subclass.

Atrial fibrillation and a heart murmur were diagnosed in a 68-year-old woman during a routine medical examination. She presented 2 years later with pulmonary edema. A transthoracic echocardiography examination revealed a tunneled atrial septal defect (ASD) and severe tricuspid regurgitation. Transesophageal echocardiography and 3-dimensional computed tomography evaluations revealed multiple intracardiac defects, including abnormal atrial septation suggestive of a typical cor triatriatum sinistrum (A1 Lam subclass), a rare congenital defect in adults. The patient underwent tricuspid valve repair with concomitant closure of the ASD by using the cor triatriatum curtain to form an autologous transposition flap. The intraoperative transesophageal and predischarge imaging evaluations confirmed an excellent repair. The patient made a swift recovery and demonstrated improvement in her symptoms at follow-up. This previously undescribed technique eliminates the need for a prosthetic implant and is applicable in >80% of cor triatriatum cases in which an ASD exists.

Is there a renoprotective value to leukodepletion during heart valve surgery? A randomized controlled trial (ROLO).

BACKGROUND: Acute Kidney Injury (AKI) adversely affects outcomes after cardiac surgery. A major mediator of AKI is the activation of leukocytes through exposure to the cardiopulmonary bypass circuit. We evaluate the use of leukodepletion filters throughout bypass to protect against post-operative AKI by removing activated leukocytes during cardiac surgery. METHODS: This is a single-centre, double-blind, randomized controlled trial comparing the use of leukodepletion versus a standard arterial filter throughout bypass. Elective adult patients undergoing heart valve surgery with or without concomitant procedures were investigated. The primary clinical outcome measured was the development of AKI according to the KDIGO criteria. Secondary measures included biomarkers of renal tubular damage (urinary Retinol Binding Protein and Kidney Injury Molecule-1), glomerular kidney injury (urinary Micro Albumin and serum Cystatin C) and urinary Neutrophil Gelatinase Associated Lipocalin, as well as the length of hospital stay and quality of life measures through EQ-5D-5L questionnaires. RESULTS: The ROLO trial randomized 64 participants with a rate of recruitment higher than anticipated (57% achieved, 40% anticipated). The incidence of AKI was greater in the leukodepletion filter group (44% versus 23%, risk difference 21, 95% CI - 2 to 44%). This clinical finding was supported by biomarker levels especially by a tendency toward glomerular insult at 48 h, demonstrated by a raised serum Cystatin C (mean difference 0.11, 95% CI 0.00 to 0.23, p = 0.068) in the leukodepleted group. There was however no clear association between the incidence or severity of AKI and length of hospital stay. On average, health related quality of life returned to pre-operative levels in both groups within 3 months of surgery. CONCLUSIONS: Leukocyte depletion during cardiopulmonary bypass does not significantly reduce the incidence of AKI after valvular heart surgery. Other methods to ameliorate renal dysfunction after cardiac surgery need to be investigated. TRIAL REGISTRATION: The trial was registered by the International Standard Randomized Controlled Trial Number Registry ISRCTN42121335 . Registered on the 18 February 2014. The trial was run by the Bristol Clinical Trials and Evaluation Unit. This trial was financially supported by the National Institute of Health Research (Research for Patient Benefit), award ID: PB-PG-0711-25,090.

Cardiac surgery during pregnancy.

Cardiovascular adaptations during pregnancy are normally well tolerated in healthy women. However, 2% to 4% of women of childbearing age have some degree of concomitant heart disease, and these changes may compromise cardiac function. Of these, a few who do not respond to medical treatment may require surgical correction. In this setting, maternal mortality rate has improved to levels similar to those in non-pregnant counterparts. However, the fetal mortality rate remains high (up to 33%). Factors contributing to high fetal mortality rates include the timing of the operation, the urgency of the operation, and the fetal/fetoplacental response to cardiopulmonary bypass. Modulation of the fetoplacental response to cardiopulmonary bypass may prevent placental dysfunction and sustained uterine contractions, which underlie fetal hypoxia and acidosis.In this article, we review cardiovascular adaptations to pregnancy and the pathophysiologic effects of cardiopulmonary bypass on the mother, fetus, and fetoplacental unit, and we talk about whether manipulation of these responses can help in improving fetal outcome. Finally, approaches regarding perfusion management and off-pump cardiac surgical techniques in pregnancy are discussed.

Retrospective Review of a Prothrombin Complex Concentrate (Beriplex P/N) for the Management of Perioperative Bleeding Unrelated to Oral Anticoagulation.

A multicenter, retrospective, observational study of 4-factor prothrombin complex concentrate (PCC) and/or fresh frozen plasma (FFP) use within routine clinical care unrelated to vitamin K antagonists was conducted. The PCC was administered preprocedure for correction of coagulopathy (prophylactic cohort) and treatment of bleeding postsurgery (treatment cohort). Of the 445 patients included, 40 were in the prophylactic cohort (PCC alone [n = 16], PCC and FFP [n = 5], FFP alone [n = 19]) and 405 were in the treatment cohort (PCC alone [n = 228], PCC and FFP [n = 123], FFP alone [n = 54]). Cardiovascular surgery was the most common setting. PCC doses ranged between 500 and 5000 IU. Effectiveness (assessed retrospectively) was reported as effective in 93.0% in the PCC-only group (95% confidence interval, 89.1% to 95.9%), 78.9% (70.8% to 85.6%) with PCC and FFP, and 86.3% (76.2% to 93.2%) with FFP alone. In the treatment cohort, international normalized ratio was significantly reduced in all 3 groups. In patients who received PCC, the rate of thromboembolic events (1.9%) was below rates in the literature for similar procedures. PCCs offer a potential alternative to FFP in the management of perioperative bleeding unrelated to oral anticoagulant therapy.

Leukocytes-depleting filters preferentially remove activated leukocytes and reduce the expression of surface adhesion molecules during the simulated extracorporeal circulation of human blood.

The effect of leukocyte-depleting filters on the total and activated leukocyte counts and the expression of surface adhesion molecules CD11b, CD18, and CD62L during the in vitro extracorporeal circulation of human blood was studied. A 200 ml blood sample was taken from 10 patients undergoing CABG surgery. The blood was circulated for 60 minutes within an experimental extracorporeal circuit. A leukocyte-depleting filter was attached in five circuits (filtered group). In five other circuits, no filter was used (controls). Total leukocyte counts were determined manually. Activated leukocytes were identified using nitroblue tetrazolium staining. The expression of CD11b, CD18, and CD62L was measured with flow cytometry. At 60 minutes, total leukocyte counts were reduced by 49% from the baseline values in the filtered group and 10% in the control group (p < 0.0001). Activated leukocyte counts decreased by 86% in the filtered group and increased by 116% in the control group (p < 0.0001). In the filtered group, the expression of CD11b, CD18, and CD612L decreased by 60%, 21%, and 79%, respectively, and in the control group it increased by 24%, 6%, and 28% (p < 0.0001). Leukocyte-depleting filters preferentially remove activated leukocytes and reduce the expression of CD11b, CD18, and CD62L during the in vitro extracorporeal circulation of human blood.

Balloon assisted retraction of a migrated CoreValve Evolut R bioprosthesis during cardiac arrest.

We describe a case of balloon assisted retraction of a migrated CoreValve Evolut R bioprosthesis during trans-femoral TAVI.

Thoracic intrathymic thyroid and cervical goiter: single-stage resection.

Ectopic thyroid tissue in the chest is rare. We report a case of a euthyroid patient with benign ectopic thyroid tissue presenting as a thymic mass in association with a multinodular goiter. Both disorders were managed successfully by surgical intervention.

Leukodepletion reduces renal injury in coronary revascularization: a prospective randomized study.

BACKGROUND: Cardiopulmonary bypass (CPB) is an important contributor to renal failure, which is a well-recognized complication after coronary artery bypass grafting (CABG). Leukodepletion reduces CPB-associated inflammation and resultant end-organ injuries. However, its effectiveness in renal protection has not been evaluated in a prospective randomized clinical setting. METHODS: Forty low-risk patients awaiting elective CABG with normal preoperative cardiac and renal function were prospectively randomized into those undergoing nonpulsatile CPB without (group A: n = 20) and with leukodepletion (group B: n = 20). Renal glomerular and tubular injury were assessed by urinary excretion of microalbumin and retinol binding protein (RBP) indexed to creatinine (Cr), respectively. Daily measurements were taken from admission to postoperative day 5. Fluid balance, serum creatinine, and blood urea were also monitored. RESULTS: No mortality or renal complication occurred. Both groups had similar demographic makeups, Parsonnet scores, extents of coronary revascularization and, durations of CPB and aortic cross-clamping. Daily fluid balance, serum creatinine, and blood urea remained comparable in both groups throughout the study period. From equal preoperative values, a significantly higher release of urinary RBP:Cr (7,807 +/- 2,227 vs 3,942 +/- 2,528; p < 0.001) and urinary microalbumin:Cr (59.4 +/- 38.0 vs 4.7 +/- 6.7; p < 0.0001) occurred in group A, peaking on day 1 before returning to approximate baseline levels. CONCLUSIONS: Although clinically overt renal complications were absent, sensitive indicators revealed significantly more injury to both renal tubules and glomeruli after nonpulsatile CPB without leukodepletion. These data suggest that leukocytes play an important role in post-CPB renal dysfunction, and leukodepletion may offer some renal protection in low-risk patients during CABG.

A prospective randomized study to evaluate splanchnic hypoxia during beating-heart and conventional coronary revascularization.

OBJECTIVE: Cardiopulmonary bypass (CPB) is associated with gut mucosal hypoxia, which may contribute to gastrointestinal complications. We examined gastric mucosal oxygenation together with whole-body oxygen flux in low-risk patients undergoing coronary artery bypass grafting (CABG) with and without CPB. METHODS: Fifty-four patients undergoing primary CABG by the same surgeon were randomized into either on-pump (ONCAB, n=27) or off-pump (OPCAB, n=27) groups. The ONCAB group underwent mild hypothermic (35 degrees C) pulsatile CPB with arterial line filtration. Each patient underwent perioperative monitoring with continuous tonometry and cardiac output devices. Gastric intramucosal pH (pHi), gastric-arterial carbon dioxide partial pressure difference (CO(2) gap), whole-body oxygen delivery (DO(2)) and consumption (VO(2)) and whole-body oxygen extraction fraction were measured at sequential time-points intraoperatively and up to 6 h postoperatively. Anaesthetic management was standardized. RESULTS: Both groups had similar demographic makeup and extent of revascularization (ONCAB 2.6+/-0.9 grafts versus OPCAB 2.5+/-0.8 grafts; P=0.55). The ONCAB group had a mean (+/-SD) CPB time of 62+/-25 min and aortic cross-clamp time of 32+/-11 min. In both groups there was a similar and progressive drop in pHi intraoperatively. Postoperatively, there was a gradual separation between the groups with ONCAB patients showing no further decline in pHi, while further deterioration was observed in the OPCAB group up to 6 h postoperatively. There was a significant difference between the groups over time (P=0.03). There was a corresponding progressive rise in CO(2) gap perioperatively in both groups, with ONCAB patients demonstrating superior preservation of gastric mucosal oxygenation in the early postoperative period. Global oxygen utilization measurements showed superior DO(2) and VO(2) in the OPCAB group throughout the study. CONCLUSIONS: Despite superior global oxygen flux associated with beating-heart revascularization, gastric mucosal hypoxia occurred to similar extents in both groups with worsening trends for the OPCAB patients postoperatively. The splanchnic pathophysiology during beating-heart revascularization should be further explored.

The effect of leucodepletion on leucocyte activation, pulmonary inflammation and respiratory index in surgery for coronary revascularisation: a prospective randomised study.

OBJECTIVE: Leucocyte activation is central to end-organ damage that occurs during cardiac surgery under cardiopulmonary bypass (CPB). Exhaled nitric oxide (NO) increases in inflammatory lung conditions and has been proposed as a marker of pulmonary inflammation during CPB. This study examined the effect of leucodepletion on leucocyte activation, pulmonary inflammation and oxygenation in patients undergoing coronary revascularisation. METHODS: Fifty low-risk patients undergoing first time coronary artery bypass graft (CABG) were randomised to two groups. Twenty-five patients had an arterial line leucocyte-depleting filter and 25 controls had a standard filter. Arterial blood samples were taken before CPB, 5 and 30 min on CPB, 5 min after aortic clamp removal and 6 h post-operatively. Activated leucocytes were identified with Nitroblue Tetrazolium staining. NO was sampled via an endotracheal teflon tube 15 min after median sternotomy before CPB and 30 min after discontinuation of CPB using a real-time chemiluminescense analyser. Respiratory index (alveolar-arterial oxygenation index, AaOI) was calculated before CPB, 1, 2, 4, 8 and 18 h post-operatively. Clinical outcome end-points were also recorded. RESULTS: Total and activated leucocyte counts were significantly lower following leucodepletion during CPB (P < 0.0001). Exhaled NO rose significantly after CPB in the control group (3.8+/-1 ppb/s before CPB vs 5.6+/-2 ppb/s after CPB (P = 0.003) but not in the leucodepleted group (3.7+/-1 ppb/s before CPB vs 3.9+/-1 ppb/s after CPB (P = 0.051). AaOIs were consistently lower after leucodepletion (anova, P = 0.001). The duration of mechanical ventilation, the intensive care and hospital stay and the frequency of cardiac and respiratory complications were similar in the two groups. CONCLUSIONS: Leucodepletion reduces the numbers of circulating activated leucocytes and the pulmonary inflammation during CPB. This appears to limit lung injury and improve oxygenation in low-risk patients undergoing CABG surgery. Larger numbers of patients are required to evaluate the effect of continuous arterial line leucodepletion on the clinical outcome.

Dopamine therapy for patients at risk of renal dysfunction following cardiac surgery: science or fiction?

OBJECTIVES: We aimed to evaluate the renoprotective role of renal-dose dopamine on cardiac surgical patients at high risk of postoperative renal dysfunction. The latter included older patients or those with pre-existing renal disease, elevated preoperative serum creatinine (Cr), poor ventricular function, hypertension, diabetes mellitus and unstable angina requiring intravenous therapy. METHODS: Fifty patients undergoing cardiopulmonary bypass (CPB) who fulfilled the entry criteria were prospectively randomized into two groups: Group 1 received a 'renal-dose' (3 microg kg(-1) min(-1)) dopamine infusion starting at anaesthetic induction for 48 h whilst saline infusion acted as placebo in Group 2. The anaesthetic and CPB regimes were standardized. Urinary excretion of retinol binding protein (RBP) indexed to Cr, an accurate and sensitive marker of early renal tubular damage, was assessed daily for 6 days. Additional outcome measures included daily fluid balance, blood urea and serum Cr. Statistical comparisons were made using ANOVA and Mann-Whitney U-test. RESULTS: No significant difference was found between the groups in their age, gender, preoperative NYHA class, ejection fraction, baseline serum Cr and duration of CPB and aortic cross-clamping. Renal replacement therapy was not required in any instance. Both groups demonstrated a similar and significant rise in urinary RBP throughout the study period. Dopamine-treated patients achieved more negative average fluid balance than those on placebo (5 vs. 229 ml, P<0.05). CONCLUSIONS: Renal-dose dopamine therapy failed to offer additional renoprotection to patients considered at increased risk of renal dysfunction after CPB.

An evidence-based approach to drainage of the pleural cavity: evaluation of best practice.

Recent surveys have uncovered major variations in key aspects of intercostal drain management, suggesting that decisions are being made on individual preferences without resorting to sound evidence. We provide an up-to-date review of the best practice with evidence-based recommendations and expert consensus views. The following aspects of chest drain management have been addressed: indications for drainage, insertion technique, complications, management of an indwelling chest drain, indications and technique for removal. The emphasis in this review is that safe intercostal drain practice relies upon adherence to a few important principles. Furthermore, when in doubt, particularly with a complex thoracic problem, one should seek prompt specialist advice.

Bronchial artery dissection and fatal hemothorax following pneumonectomy.

A 59-year-old man died suddenly and unexpectedly two days after an uncomplicated pneumonectomy for bronchogenic adenocarcinoma. In addition to a distal pulmonary thromboembolism found at postmortem, there was significant hemorrhaging into the pneumonectomy space, which was associated with rupture of a dissecting aneurysm in the calcified bronchial artery stump. The pathology and surgical implications of bronchial artery disease are discussed.

Staged hybrid treatment for contained rupture of a large right coronary artery aneurysm.

We describe a staged approach to the management of a rare acute condition--contained rupture of a large right coronary artery aneurysm. A covered stent was deployed percutaneously to isolate the aneurysm at presentation followed by planned coronary bypass grafting. Treatment interval was complicated by new-onset pulmonary tuberculosis and subacute thrombosis of the covered stent leading to nonfatal inferior myocardial infarction. Coronary surgery was performed after complete antitubercular treatment and resolution of the acute pericarditis/thrombosis as a consequence of the contained rupture. The advantages of this staged approach included the following: (a) The covered stent prevented both acute myocardial infarction and progressive pseudoaneurysm expansion in the acute phase. (b) Deferred surgery was rendered technically less hazardous while avoiding the undesirable option of having to exclude an extremely calcified dominant right coronary artery. The patient made an excellent postoperative recovery with complete resolution of her symptoms at 6 weeks' follow-up.

Early and late prognostic implications of coronary artery bypass timing after myocardial infarction.

OBJECTIVES: The optimal timing of coronary artery bypass grafting (CABG) after myocardial infarction (MI) is still controversial. With advances in perioperative care and myocardial protection, CABG is not infrequently undertaken sooner. Although CABG soon after MI is associated with high morbidity and mortality, the impact of CABG timing on late survival is not clear. METHODS: We analysed prospectively collected data for 8320 patients who underwent primary CABG from 1996 through 2010. Operative outcomes and late survival were compared between patient categories based on MI-to-CABG days: groups A (0-30, n = 658), B (31-60, n = 734), C (>90, n = 2698) and D (no MI, n = 4230). The effect of the timing of surgery on survival was determined using multivariate and Kaplan-Meier analyses. RESULTS: As the MI-to-CABG interval increased, the frequency of urgent/emergency operations decreased and hospital mortality (A, 3.5% vs B, 2.6% vs C, 1.2%, vs D, 1.1%, P < 0.0001) steadily declined. In general, patients who had CABG within 90 days of MI had more cardiac morbidity and co-morbidities. Expectedly, therefore, postoperative organ system dysfunction (cardiac, renal, respiratory and neurological) was more frequent in these groups. Reoperation for bleeding was similar for all groups, but blood product transfusion decreased as the MI-to-CABG days increased. The 10-year survival improved with the MI-to-CABG interval (A, 72.2% vs B, 73.4% vs C, 75.8% vs D, 81.4%, P < 0.0001). By multivariate analysis, the MI-to-CABG interval was not a risk factor for operative or late mortality. However, less frequent were left internal mammary artery use, non-elective surgery and high blood transfusion rates; all more often associated with shorter MI-to-CABG intervals. CONCLUSIONS: Early and late mortality risk for CABG declines with increasing interval from MI for reasons indirectly linked to the timing of surgery. Our findings emphasize the importance of preoperative organ system optimization and consistent left internal mammary artery use, regardless of the proximity of surgery to MI or the exigency of surgery.

Risk modeling for ventricular assist device support in post-cardiotomy shock.

BACKGROUND: Post-cardiotomy shock (PCS) has a complex etiology. Although treatment with inotrops and intra-aortic balloon pump (IABP) support improves cardiac performance, end-organ injuries are common and lead to prolonged ICU stay, extended hospitalization and increased mortality. Early consideration of mechanical circulatory support may prevent such complications and improve outcome. METHODS: Between January 1997 and January 2002, 321 patients required IABP and inotropic support for PCS following coronary artery bypass grafting (CABG) at our institution. Perioperative variables including age, mixed venous saturation (MVO2), inotropic requirements and LV function were analyzed using multivariate statistical methods. All explanatory variables with a univariate p value <0.10 were entered into a stepwise logistic regression model to predict hospital mortality. Odds ratios from significant variables (p < 0.05) in the regression model were used to compose a risk score. RESULTS: Overall hospital mortality was 16%. The independent risk factors for mortality in this population were: MVO2 < 60% (OR = 3.2), milrinone > 0.5 µg/kg/min (OR = 3.2), age > 75 (OR = 2.7), adrenaline > 0.1 µg/kg/min (OR = 1.5). A 15-point risk score was developed based on the regression model. Hospital mortality in patients with a score >6 was 46% (n = 13/28), 3-6 was 31% (n = 9/29) and <3 was 11% (n = 29/264). CONCLUSIONS: A significant proportion of patients with PCS continue to face high mortality despite IABP and inotropic support. Advanced age, heavy inotropic dependency and poor oxygen delivery all predicted increased risk for death. Further investigation is needed to assess whether early institution of VAD support could improve outcome in this high-risk group of patients.

Is a fully heparin-bonded cardiopulmonary bypass circuit superior to a standard cardiopulmonary bypass circuit?

A best-evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Is a fully heparin bonded cardiopulmonary bypass circuit superior to a standard cardiopulmonary bypass circuit?' Altogether more than 792 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated (Table 1). The studies analysed show that perfusion with heparin-coated and heparin-polymer-coated bypass does not increase the risk of adverse effects but reduces blood loss, re-operation rates, ventilation time, length of intensive care unit (ICU) and hospital stay and is also associated with improved biocompatibility, as evidenced by platelet preservation, reduced leucocyte and complement activation, and proinflammatory cytokine production. The various coated circuits have comparable biocompatibility as evaluated by a range of inflammatory markers and clinical outcomes. Three studies documented a significant decrease in post-operative blood loss (P = 0.001-0.54) and a meta-analysis found that perfusion with a heparin-bonded circuit resulted in a reduction in blood transfusion requirements (20%), ventilation time (P < 0.01), length of time in the ICU (P < 0.01) and also hospital stay (P = 0.02). Two studies found reduced levels of polymorphonuclear elastase (P < 0.018-0.001) and two trials concluded that the use of heparin-coated circuits in combination with low-dose systemic heparin (activated clotting time >250) resulted in the greatest clinical benefit and improvement in inflammation. One study documented significant platelet preservation with the use of third-generation heparin-polymer-bonded circuits (P ≤ 0.05). We conclude that despite heparin-bonded and newer third-generation heparin-polymer-bonded cardiopulmonary bypass circuits having a greater cost per person, their improved clinical outcomes and biocompatibility in patients undergoing cardiac surgery make them a preferable option to standard non-heparin-bonded circuits.