Impact of a blood conservation program on 30-day morbidity and mortality: a cohort study.

BACKGROUND: There are little published data on outcomes of blood conservation (BC) patients after noncardiac surgery. The objective of this study was to compare the surgical outcomes of patients enrolled in our BC program with that of the general population of surgical patients. METHODS: BC patients at our institution undergoing various surgical procedures were identified from the 2007-2009 National Surgical Quality Improvement Program database and compared with a cohort of conventional care (CC) patients matched by age, gender, and surgical procedure. Univariate and multiple logistic regression analyses were performed to evaluate 30-d postoperative outcomes. RESULTS: One hundred twenty BC patients were compared with 238 CC patients. The two groups were similar for all preoperative variables except smoking, which was lower in the BC group. On univariate analysis, BC patients had similar mean operating time (148 versus 155 min; P = 0.5), length of stay (5.9 versus 5.5 d; P = 0.7), and rate of return to the operating room (7.5% versus 5.5%; P = 0.4) compared with CC patients. BC and CC patients had similar 30-d morbidity (18% versus 14%; P = 0.3) and mortality rates (1.6% versus 1.3%; P = 1.0), respectively. On multivariable analysis, enrollment in the BC program had no impact on postoperative 30-d morbidity (odds ratio, 1.78; 95% confidence interval, 0.71-4.47) or 30-d mortality (unadjusted odds ratio, 1.33; 95% confidence interval, 0.22-8.05). CONCLUSIONS: Short-term postoperative outcomes in BC patients are similar to the general population, and these patients should not be denied surgical treatment based on their unwillingness to receive blood products.

Coronary artery bypass graft: why is the saphenous vein prone to intimal hyperplasia?

Proliferation and migration of smooth muscle cells and the resultant intimal hyperplasia cause coronary artery bypass graft failure. Both internal mammary artery and saphenous vein are the most commonly used bypass conduits. Although an internal mammary artery graft is immune to restenosis, a saphenous vein graft is prone to develop restenosis. We found significantly higher activity of phosphatase and tensin homolog (PTEN) in the smooth muscle cells of the internal mammary artery than in the saphenous vein. In this article, we critically review the pathophysiology of vein-graft failure with detailed discussion of the involvement of various factors, including PTEN, matrix metalloproteinases, and tissue inhibitor of metalloproteinases, in uncontrolled proliferation and migration of smooth muscle cells towards the lumen, and invasion of the graft conduit. We identified potential target sites that could be useful in preventing and (or) reversing unwanted consequences following coronary artery bypass graft using saphenous vein.

Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing elective vascular operations.

OBJECTIVE: The objective of this study was to assess the impact of preoperative anemia (hematocrit <39%) on postoperative 30-day mortality and adverse cardiac events in patients 65 years or older undergoing elective vascular procedures. BACKGROUND: Preoperative anemia is associated with adverse outcomes after cardiac surgery, but its association with postoperative outcomes after open and endovascular procedures is not well established. Elderly patients have a decreased tolerance to anemia and are at high risk for complications after vascular procedures. METHODS: Patients (N = 31,857) were identified from the American College of Surgeons' 2007-2009 National Surgical Quality Improvement Program-a prospective, multicenter (>250) database maintained across the United States. The primary and secondary outcomes of interest were 30-day mortality and a composite end point of death or cardiac event (cardiac arrest or myocardial infarction), respectively. RESULTS: Forty-seven percent of the study population was anemic. Anemic patients had a postoperative mortality and cardiac event rate of 2.4% and 2.3% in contrast to the 1.2% and 1.2%, respectively, in patients with hematocrit within the normal range (P < 0.0001). On multivariate analysis, we found a 4.2% (95% confidence interval, 1.9-6.5) increase in the adjusted risk of 30-day postoperative mortality for every percentage point of hematocrit decrease from the normal range. CONCLUSIONS: The presence and degree of preoperative anemia are independently associated with 30-day death and adverse cardiac events in patients 65 years or older undergoing elective open and endovascular procedures. Identification and treatment of anemia should be important components of preoperative care for patients undergoing vascular operations.

Pseudo-pseudoaneurysm of the left ventricle: a rare complication of acute myocardial infarction--a case report and literature review.

Rupture of the cardiac wall is usually a fatal complication of acute myocardial infarction within the first 2 weeks. However, in certain cases a ruptured ventricular wall is contained by overlying adherent pericardium called pseudoaneurysm, whereas a true aneurysm is one that is caused by scar formation resulting in thinning of the myocardium. The patients with pseudoaneurysm may survive until the aneurysm ruptures. In exceedingly rare instance, the rupture of the myocardium is not transmural but remains circumscribed within the ventricular wall itself, but in communication with the ventricular cavity. This finding is defined as pseudo-pseudoaneurysm. The authors report a case of postinfarction posterobasal pseudo-pseudoaneurysm along with review of the literature on the subject.

Amiodarone versus sotalol for the treatment of atrial fibrillation after open heart surgery: the Reduction in Postoperative Cardiovascular Arrhythmic Events (REDUCE) trial.

OBJECTIVES: This prospective, randomized, double-blind, placebo-controlled study compared the efficacy and safety of amiodarone and sotalol in the prevention of atrial fibrillation (AF) following open heart surgery. BACKGROUND: The incidence of supraventricular arrhythmias following open heart surgery ranges from 20% to 40%, with AF being the most common. Both amiodarone and sotalol have been shown to be effective in reducing postoperative arrhythmias, but no direct comparison of these agents has been conducted. METHODS: A total of 160 patients were randomized, of whom 134 underwent coronary artery bypass graft surgery (CABG) alone, 17 underwent CABG and concomitant aortic valve replacement surgery (AVR), 9 underwent AVR only, and 1 patient's surgery was canceled. Patients with signs or symptoms of congestive heart failure (CHF), ejection fraction < or =30%, estimated creatinine clearance <30 mL/min, or serum creatinine > or =2.5 mg/dL were excluded. Patients were randomized to receive either sotalol 80 mg 2 times per day (n = 76) or intravenous amiodarone 15 mg/kg over 24 hours followed by oral amiodarone 200 mg 3 times per day (n = 83). Study drug was started at the time of surgery and continued for 7 days or until discharge, whichever came first. RESULTS: AF occurred in 17% of patients randomized to amiodarone and 25% of the patients randomized to sotalol (P =.21). However, the duration of AF was significantly shorter in amiodarone-treated patients (169 +/- 224 min) compared to sotalol treated patients (487 +/- 505 min; P =.04). In a subgroup analysis, the incidence of AF in patients undergoing AVR or CABG with AVR was significantly less with amiodarone (1/15, 7%) compared to sotalol (9/11, 82%) (P <.001). Blood pressure was lower immediately after surgery with amiodarone but comparable to sotalol at 24 hours. Of the hemodynamic indices measured, only stroke volume was significantly lower in patients randomized to sotalol at 24 hours (P =.035). CONCLUSIONS: Amiodarone and sotalol share similar efficacy and safety in reducing postoperative AF. Hemodynamic effects were similar between both drugs at 24 hours, with the exception that stroke volume was lower in sotalol-treated patients. In patients undergoing more complex surgery, postoperative AF occurred more frequently with sotalol than with amiodarone.

Conservative management of traumatic lung hernia.

Traumatic lung hernia is a rare entity. The majority of cases reported in the literature have been treated surgically with early thoracotomy to prevent strangulation of pulmonary tissue. We report the case of a 63-year-old patient who experienced a 20-foot fall, causing multiple rib fractures with a lung hernia that was managed conservatively for 48 hours followed by spontaneous resolution of the herniated pulmonary segment. There is a need to review the indications for surgical versus conservative approach in the management of posttraumatic lung hernia.

A meta-analysis of randomized controlled trials in critically ill patients to evaluate the dose-response effect of erythropoietin.

The use of erythropoietin in critically ill patients has been investigated in multiple randomized clinical trials and its role in decreasing the number of units of blood transfused has been demonstrated in some trials. A meta-analysis was conducted to determine the pooled estimate of the decrease in number of units of blood transfused with the use of erythropoietin and investigated its dose-response effect. A systematic search was performed of the MEDLINE, EMBASE, and the Current Controlled Trials Register to identify randomized clinical trials investigating the role of erythropoietin in critically ill patients. Of 664 studies identified in the search, 5 randomized clinical trials met the inclusion criteria. The pooled estimate of the decrease of number of units of blood transfused was -1.64 (95% CI -2.6 to -0.67). Sensitivity analysis to establish the influence of temporal bias, quality of the study and comorbidities such as age and Acute Physiology and Chronic Health Evaluation (APACHE) II score were undertaken and did not reveal a significant difference. The inclusion of studies with higher doses of erythropoietin revealed a greater decrease in the number of units of blood transfused (-2.15; 95% CI -3.06 to -1.24). Despite the limitations of a meta-analysis we believe that the use of erythropoietin significantly decreases the number of units of blood transfused per patient. Our study also reveals the possibility of a dose-response effect of erythropoietin in decreasing the number of units of blood transfused.

Differential effects of calpain inhibitors on hypertrophy of cardiomyocytes.

Two inhibitors of the calcium-dependent cysteine protease, calpain, have markedly different effects on the extent of hypertrophy induced by the alpha-adrenergic agonist, phenylephrine, of cultured neonatal rat ventricular myocytes. E64c, an inhibitor of calpain and other cysteine proteases, stimulated the hypertrophy by 59%. PD 150606, a specific calpain inhibitor, reduced the hypertrophy by 38%. Phenylephrine decreased the proteolysis of a calpain substrate by the cells 1-2 h after its addition but not at 24 h. PD 150606 inhibited proteolytic activity at all times, and the combination of phenylephrine and PD 150606 did not give greater inhibition. This suggests that cysteine proteases of the papain sub-family are involved with the hypertrophic response at two points, promoting hypertrophy at the first and limiting it at the second. Calpain appears to be the protease involved at the first point, and there may be another cysteine protease acting at the second site.