ECMO as a bridge to high-risk rotablation of heavily calcified coronary arteries.

Mechanical circulatory support (MCS) with short-term ventricular assist devices has been used as a bridge to high-risk percutaneous coronary interventions (PCI), as well as during interventions and in the post-procedural recovery period. Percutaneous extracorporeal membrane oxygenation (ECMO) is used when full cardiopulmonary support is necessary due to severe biventricular and pulmonary dysfunction. Prompted by two cases of high-risk rotablation of heavily calcified coronary arteries where ECMO was used as a bridge to intervention and post-intervention recovery, we reviewed the bibliography and the new guidelines on cardiac revascularization with regard to the utility of MCS devices in high-risk PCI cases.

Adult congenital heart disease in Greece: Preliminary data from the CHALLENGE registry.

BACKGROUND: The majority of patients with congenital heart disease (CHD), nowadays, survives into adulthood and is faced with long-term complications. We aimed to study the basic demographic and clinical characteristics of adult patients with congenital heart disease (ACHD) in Greece. METHODS: A registry named CHALLENGE (Adult Congenital Heart Disease Registry. A registry from Hellenic Cardiology Society) was initiated in January 2012. Patients with structural CHD older than 16years old were enrolled by 16 specialized centers nationwide. RESULTS: Out of a population of 2115 patients with ACHD, who have been registered, (mean age 38years (SD 16), 52% women), 47% were classified as suffering from mild, 37% from moderate and 15% from severe ACHD. Atrial septal defect (ASD) was the most prevalent diagnosis (33%). The vast majority of ACHD patients (92%) was asymptomatic or mildly symptomatic (NYHA class I/II). The most symptomatic patients were suffering from an ASD, most often the elderly or those under targeted therapy for pulmonary arterial hypertension. Elderly patients (>60years old) accounted for 12% of the ACHD population. Half of patients had undergone at least one open-heart surgery, while 39% were under cardiac medications (15% under antiarrhythmic drugs, 16% under anticoagulants, 16% under medications for heart failure and 4% under targeted therapy for pulmonary arterial hypertension). CONCLUSIONS: ACHD patients are an emerging patient population and national prospective registries such as CHALLENGE are of unique importance in order to identify the ongoing needs of these patients and match them with the appropriate resource allocation.

Acute intraoperative heparin-induced thrombocytopenia (HIT) and thrombosis during coronary artery bypass grafting: Two case reports providing evidence for the role of preoperative LMWH in triggering sensitization.

INTRODUCTION: Systemic anticoagulation is necessary during cardiac surgery. To date, the only well established anticoagulation protocol involves the use of heparin. However, heparin can cause heparin-induced thrombocytopenia (HIT) a potentially life threatening immune-mediated thromboembolic syndrome. Until now, devastating consequences of HIT syndrome in patients undergoing heart surgery have been described, but only postoperatively. Here we report the development of HIT syndrome during cardiac revascularization by intra-operative heparin administration in two patients previously exposed to LMWH. PATIENTS/METHODS: We report on two patients who developed rapid and profound intravascular coagulation with severe thrombocytopenia (platelet count decreased from ≥250×109/L to 50×109/L) due to HIT development caused by heparin administration during coronary artery bypass graft surgery. In addition we report that fondaparinux, given intra-operatively in association with antithrombin, may be a suitable alternative anticoagulant for successfully preventing the devastating consequences of intra-operative HIT development. CONCLUSION: To our knowledge, this is the first report describing the development of acute intra-operative HIT, secondary to high-dose UFH administered for coronary revascularization, in which the unexpected presence of platelet-activating anti-PF4/heparin antibodies at surgery was explained by preoperative administration of a one-week course of LMWH but without any preoperative evidence for HIT.

Implementation of EuroSCORE II as an adjunct to APACHE II model and SOFA score, for refining the prognostic accuracy in cardiac surgical patients.

AIM: The aim of this paper was to assess the comparable applicability of European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure (SOFA) scores, in cardiac surgical population, on the basis of morbidity and mortality. METHODS: EuroSCORE II, APACHE II score and SOFA score derivatives such as TMS (total maximum SOFA), MaxSOFA (single-day maximum total), SOFA 1 (admission SOFA), ΔSOFA (TMS minus SOFA 1), ΔmaxSOFA (MaxSOFA minus SOFA 1) and mean SOFA (daily SOFA to ICU stay), were prospectively calculated for 1058 consecutive patients admitted to postcardiac surgery intensive care unit (ICU). The study endpoints were length of ICU stay (LOS-ICU) and hospital mortality. RESULTS: A disproportionate elevation of the studied algorithms was associated with prolonged LOS-ICU (P<0.001). TMS, MeanSOFA, MaxSOFA and EuroSCORE II provided better discrimination for in-hospital death [area under the receiver operating characteristic curve (AUC) 0.949, 0.929, 0.927 and 0.906, respectively] and LOS-ICU more than 2 days (AUC 0.853, 0.823, 0.819 and 0.806, respectively), compared to other risk models. EuroSCORE II, TMS and MeanSOFA were also identified as independent predictors of prolonged LOS-ICU. CONCLUSION: EuroSCORE II seems to confer noteworthy prognostic value, being almost equivalent to that of TMS, MeanSOFA and MaxSOFA scores, and superior than APACHE II in cardiac surgical population. Thus, EuroSCORE II emerges as an imperative adjunct to ICU-based APACHE II and SOFA algorithms as it enables risk stratification, morbidity and mortality prediction even from preoperative assessment.

Reduced postoperative blood loss and transfusion requirement after beating-heart coronary operations: a prospective randomized study.

OBJECTIVE: Coronary artery bypass grafting on the beating heart through median sternotomy is a relatively new treatment, which allows multiple revascularization without the use of cardiopulmonary bypass. A prospective randomized study was designed to investigate the effect of coronary bypass with or without cardiopulmonary bypass on postoperative blood loss and transfusion requirement. METHODS: Two hundred patients with coronary artery disease were prospectively randomized to (1) on-pump treatment with conventional cardiopulmonary bypass and cardioplegic arrest and (2) off-pump treatment on the beating heart. Postoperative blood loss identified as total chest tube drainage, transfusion requirement, and related costs together with hematologic indices and clotting profiles were analyzed. RESULTS: There was no difference between the groups with respect to preoperative and intraoperative patient variables. The mean ratio of postoperative blood loss and 95% confidence interval between groups was 1.64 and 1.39 to 1.94, respectively, suggesting on average a postoperative blood loss 1.6 times higher in the on-pump group compared with the off-pump group. Seventy-seven patients in the off-pump group required no blood transfusion compared with only 48 in the on-pump group (P <.01). Furthermore, less than 5% of patients in the on-pump group required fresh frozen plasma and platelet transfusion compared with 30% and 25%, respectively, in the on-pump group (both P <.05). Mean transfusion cost per patient was higher in the on-pump compared with that in the off-pump group ($184.8 +/- $35.2 vs $21.47 +/- $6.9, P <.01). CONCLUSIONS: Coronary artery bypass grafting on the beating heart is associated with a significant reduction in postoperative blood loss, transfusion requirement, and transfusion-related cost when compared with conventional revascularization with cardiopulmonary bypass and cardioplegic arrest.

A new strategy of total arterial revascularization.

We report a new strategy of total arterial revascularization based on bilateral internal thoracic arteries (ITAs) and a radial artery (RA). The technique employs a graft extension of the proximal third of the right internal thoracic artery (RITA) with the RA, in combination with the T-graft technique, by which the lower two-thirds of the free RITA is anastomosed to the side of the left internal thoracic artery (LITA).

Economic outcome of off-pump coronary artery bypass surgery: a prospective randomized study.

BACKGROUND: Emphasis on cost containment in coronary artery bypass surgery is becoming increasingly important in modern hospital management. The revival of interest in off-pump (beating heart) coronary artery bypass surgery may influence the economic outcome. This study examines these effects. METHODS: Two hundred patients undergoing first-time coronary artery bypass surgery were prospectively randomized to either conventional cardiopulmonary bypass and cardioplegic arrest or off-pump surgery. Variable and fixed direct costs were obtained for each group during operative and postoperative care. The data were analyzed using parametric methods. RESULTS: There was no difference between the groups with respect to pre- and intraoperative patient variables. Off-pump surgery was significantly less costly than conventional on-pump surgery with respect to operating materials, bed occupancy, and transfusion requirements (total mean cost per patient: on pump, $3,731.6+/-1,169.7 vs off-pump, $2,615.13+/-953.6; p < 0.001). Morbidity was significantly higher in the on-pump group, which was reflected in an increased cost. CONCLUSIONS: Off-pump revascularization offers a safe, cost-effective alternative to conventional coronary revascularization with cardiopulmonary bypass and cardioplegic arrest.

Inflammatory response after coronary revascularization with or without cardiopulmonary bypass.

BACKGROUND: We sought to investigate the effect of multiple coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (CPB) on the perioperative inflammatory response. METHODS: Sixty patients undergoing CABG were randomly assigned to one of two groups: (A) on pump with conventional CPB and cardioplegic arrest, and (B) off pump on the beating heart. Serum samples were collected for estimation of neutrophil elastase, interleukin 8 (IL-8), C3a, and C5a preoperatively and at 1, 4, 12, and 24 hours postoperatively. Furthermore, white blood cell (WBC), neutrophil, and monocyte counts were carried out preoperatively and at 1, 12, 36 and 60 hours postoperatively. Overall incidence of infection and perioperative clinical outcome were also recorded. RESULTS: The groups were similar in terms of age, weight, gender ratio, extent of coronary disease, left ventricular function, and number of grafts per patient. Neutrophil elastase concentration peaked early after CPB in the on-pump group, with a decline with time. Repeated-measures analysis of variance between groups and comparisons at each time point (modified Bonferroni) showed elastase concentrations were significantly higher in the on-pump than the off-pump group (both p < 0.0001). IL-8 increased significantly after surgery in the on-pump group, with no decline during the observation period (p = 0.01 vs off pump). C3a and C5a rose early after surgery in both groups when compared with baseline values. Postoperative WBC, neutrophil, and monocyte counts were significantly higher in the on-pump than the off-pump group (p < 0.01). Finally, the incidence of postoperative overall infections was significantly higher in the on-pump group (p < 0.0001 vs off pump). CONCLUSIONS: CABG on the beating heart is associated with a significant reduction in inflammatory response and postoperative infection when compared with conventional revascularization with CPB and cardioplegic arrest.

Smooth muscle tumors of the gastrointestinal tract. A 10-year experience.

Benign or malignant smooth muscle tumors of the gastrointestinal tract are uncommon. The diagnostic and therapeutic approaches vary depending on the histological behavior of these neoplasms. Between 1981 and 1991, 32 patients with gastrointestinal tumors were treated at the Department of Surgery of the University of Patras. There were 16 females and 16 males. The mean age at the time of diagnosis was 61.9 years (range 22-83 years). Eighty-one per cent of the tumors were discovered in asymptomatic patients by a variety of diagnostic studies. Fifty-six per cent of tumors were located in the stomach, 38% in the small intestine and 6% in the colon. Leiomyomas made up 71.8% of these tumors and were treated by conservative excision. The malignant smooth muscle tumors were treated by radical excision in four cases and conservative excision in one case. The 5-year survival rate was 85% for leiomyomas and 0% for malignant smooth muscle tumors. There is widespread agreement that wide resection of the lesion is the appropriate treatment for these tumors. The size and mitotic activity of these tumors remain the most important diagnostic parameters and prognostic factors.

Off pump coronary bypass grafting of the circumflex artery.

The circumflex artery is the most challenging vessel to be grafted off pump, since it requires lifting and rotating of the heart. A method of exposure and stabilisation of the circumflex during construction of the anastomosis is described. The technique, which is routinely used in our institution, is effective, simple and safe.

Haemodynamic changes during beating heart coronary surgery with the 'Bristol Technique'.

OBJECTIVES: Optimal exposure and stabilization of the target coronary vessel is essential to allow the construction of a precise coronary anastomosis during off pump coronary surgery. However, this might be achieved at the expense of significant haemodynamic deterioration, particularly while grafting the circumflex and the posterior descending coronary arteries. The present study was designed to assess the haemodynamic changes with the beating heart positioned for grafting the three main coronaries. METHODS: Twenty-nine consecutive patients (21 male, mean age 62.6+/-7.1 years) undergoing off pump coronary surgery were enrolled in the study. Three different surgical settings of exposure and stabilization were used according to the site of anastomosis: left anterior descending (LAD - set-up 1; n=29), posterior descending (PDA - set-up 2; n=15), and circumflex (Cx - set-up 3; n=21) coronary arteries. Haemodynamic measurements were recorded before any cardiac manipulation (baseline) in set-ups 1, 2 and 3, and immediately after the completion of each distal anastomosis with the heart returned to its anatomical position. RESULTS: There were no marked changes in heart rate (HR) and systemic mean arterial pressure during the construction of the anastomoses for any of the three surgical settings. Set-up 1 (LAD) showed a decrease of 15.5% in stroke volume (SV) and an increase of 9% in pulmonary capillary wedge pressure (PCWP) compared to baseline (both P<0.05), with all the other haemodynamic parameters remaining unchanged. Set-up 2 (PDA) showed a marked decrease in SV and cardiac index (CI), and an increase in central venous pressure (CVP) when compared to baseline (all P<0.05). The most extensive changes were observed in set-up 3 (Cx) with a considerable reduction in SV and CI, and an increase in CVP, PCWP, pulmonary arterial pressure, and systemic vascular resistance index (all P<0.05). These haemodynamic changes were transient and totally recovered after the heart was returned to its anatomical position. CONCLUSIONS: Exposure and stabilization of the three main coronary arteries during beating heart surgery does not produce any appreciable change in systemic blood pressure and HR. The haemodynamic deterioration observed during the construction of the circumflex and posterior descending coronary arteries distal anastomoses is transient and well tolerated with no adverse clinical events.

Acute heart failure: is there a role for surgery?

Many of the disorders and lesions leading to acute heart failure can be treated surgically. Modern surgical techniques like the off pump coronary surgery, newer techniques for the surgical treatment of the mechanical complications of acute MI and valvular reparative techniques have been added to the surgical armamentarium in recent years. Modern ventricular assist devices have started their career in the clinical arena promising to be less invasive. At the same time the spectrum of indications for mechanical circulatory support continues to witness a rapid expansion. Technical advances have led to an evolution of surgical strategies. Heart failure surgery is now in a position to offer improved outcomes, avoidance of recurrence of acute heart failure or the development of advanced chronic heart failure.

Oesophageal perforation following perioperative transoesophageal echocardiography.

Transoesophageal echocardiography (TOE) is being used more often by cardiothoracic anaesthetists for the perioperative management of cardiac problems. Reports of iatrogenic oesophageal perforation by instrumentation of the oesophagus are increasing. Although TOE is considered safe, it may be more risky during surgery, because the probe is passed and manipulated in an anaesthetized patient. It may be in place for several hours so the risk of mucosal pressure and thermal damage is increased. Patients on cardiopulmonary bypass are also fully anticoagulated. We describe a case of oesophageal perforation following insertion of the TOE probe in a patient with gross cardiomegaly. Oesophageal distortion by cardiac enlargement may increase the risk of oesophageal perforation. Difficulty in passage of the TOE probe should be regarded with suspicion and withdrawal should be contemplated because the symptoms of oesophageal perforation are often delayed and non-specific. Delay in investigation, diagnosis and treatment will increase morbidity and mortality.