A comparison of ON-PUMP vs OFF-PUMP coronary artery bypass surgery among low, intermediate, and high-risk patients: the Hartford Hospital experience.

BACKGROUND: Off-pump coronary artery bypass (OP-CAB) graft surgery is being used with increasing frequency. This study was designed to compare OP-CAB outcomes with conventional surgical revascularization using cardiopulmonary bypass (CPB) in patients with varying risk categories at a high-volume center. METHODS AND RESULTS: Between 1/1/1999 and 1/31/2001, bypass surgery was performed on 1,312 patients, including 348 OP-CAB cases and 964 CPB cases. Compared to CPB cases, OP-CAB patients were more likely to be female and had a lower incidence of three vessel coronary artery disease, prior percutaneous intervention, and prior bypass surgery. Postoperatively, OP-CAB patients had a lower incidence of renal failure and prolonged ventilatory support, as well as a lower composite endpoint of inhospital mortality, perioperative myocardial infarction, cerebrovascular accident, and/or renal failure. In addition, OP-CAB patients required fewer transfusions and had a shorter total length of hospital stay. In general, morbidity and mortality increased in both OP-CAB and CPB groups with increasing Parsonnet score. CONCLUSIONS: OP-CAB surgery is a safe and effective alternative to conventional coronary artery bypass graft (CABG) surgery, with a lower incidence of major in-hospital adverse clinical events and a decreased requirement for medical resources. Adverse OP-CAB outcomes correlate well with pre-operative Parsonnet Score.

Complete lobar collapse following pulmonary lobectomy. Its incidence, predisposing factors, and clinical ramifications.

STUDY OBJECTIVE: To define the most severe form of postlobectomy atelectasis and determine its incidence, predisposing factors, and clinical ramifications. DESIGN: Retrospective case control. SETTING: The thoracic surgery unit at a 900-bed tertiary care hospital. PATIENTS OR PARTICIPANTS: Two hundred eighteen patients undergoing pulmonary lobectomy or bilobectomy over a 7-year time period. MEASUREMENTS AND RESULTS: Severe postlobectomy atelectasis (SPLA) was defined as complete ipsilateral lobar or bilobar collapse with whiteout of the involved lobe(s) and mediastinal shift on the chest radiograph. Data were collected consisting of patient age, lobe(s) resected, type of postoperative pain control, length of hospital and ICU stay, preoperative pulmonary function, and single- vs double-lumen tube intubation during surgery. The incidence of SPLA was 7.8%, comprising 24.6% of all postoperative complications seen. There was no statistically significant difference in patient age, preoperative room air PO2, and preoperative FEV1/FVC ratio for the SPLA group vs the group without this complication. Patients with SPLA had significantly longer ICU stays (112.7 h vs 28.4 h; p < 0.001) and hospital stays (14.7 days vs 9.3 days; p < 0.001) than the patients without complications. Patients undergoing right upper lobectomy, both alone or in combination with the right middle lobe, had a significantly higher incidence of SPLA when compared with all other types of resections (15.5% vs 3.0%; p < 0.005). There was no influence on the incidence of SPLA when the types of postoperative pain control regimen and endotracheal tubes used were examined. CONCLUSIONS: We conclude that SPLA as defined in this study is an important postoperative complication with a significant incidence. Although patients undergoing right upper lobectomy are markedly predisposed to this problem, the exact pathophysiology remains unclear. Factors shown to be causes of less severe forms of postoperative atelectasis do not seem to contribute to the formation of SPLA, indicating that these two complications may be two unrelated entities.

Fast-track recovery of the coronary bypass patient.

A new approach termed "fast-track recovery" ws undertaken at both the Baystate Medical Center and Hartford Hospital. The fast-track protocol involves the following principles: (1) preoperative education; (2) early extubation; (3) methylprednisolone sodium succinate before bypass followed by dexamethasone for 24 hours postoperatively; (4) prophylactic digitalization, metoclopramide HCl, docusate sodium, and ranitidine HCl; (5) accelerated rehabilitation; (6) early discharge; (7) a dedicated fast-track coordinator to perform both daily telephone contact and a 1-week postoperative examination; and (8) a routine 1-month postoperative visit with a PA or MD. To evaluate the effects of this approach on patient care, a retrospective 1-year analysis was undertaken in both institutions with all coronary artery bypass grafting patients compared in a consecutive manner before the origin of the fast-track protocol and subsequent to its beginning. There were 280 patients in the fast-track and 282 in the non-fast-track group. The two groups were not significantly different except inexplicably there was a lower ejection fraction in the fast-track group and a longer cross-clamp time. Postoperatively, the mean time to extubation decreased from 22.1 to 15.4 hours, and peak weight gain decreased from 2.8 to 1.6 kg from the non-fast-track to the fast-track group (p < 0.01). This was accompanied by significant (p < 0.001) decreases in intensive care unit duration from 2.4 to 1.9 days and in postoperative length of stay from 8.3 to 6.8 days from the non-fast-track to the fast-track group. There was no increase in morbidity or mortality associated with the fast-track protocol either early or late. Thirty-day hospital readmission was not significantly different between the two groups. Fast-track methodology is effective, and we routinely employ this approach for all patients undergoing cardiopulmonary bypass.

Cardiovascular and sensory responses to forearm ischemia and dynamic hand exercise.

The relationship between cardiovascular responses and pain produced by the submaximal-effort tourniquet procedure was evaluated in healthy humans. Graded increases in ischemic pain were associated with graded elevations in arterial blood pressure, forearm vascular resistance, and venous tone. Many of the vascular responses to muscle ischemia were typical of the cardiovascular components of the defense reaction and correlated with both the sensory and affective aspects of ischemic pain. The cardiovascular responses to arm ischemia were distinguishable from those produced by rhythmic hand exercise used to produce ischemia. Dynamic hand exercise produced a transient increase in arterial blood pressure, heart rate, and measures of hand discomfort. These responses were enhanced when dynamic hand exercise was conducted under ischemic conditions. The tightly coupled and coordinated cardiovascular responses elicited by ischemic pain represent integrated adaptive responses to painful stimulation.

Arteriovenous fistula of internal mammary artery after median sternotomy.

A female patient who had undergone median sternotomy for coronary artery bypass was found to have a continuous murmur on examination one month postoperatively. An arteriovenous fistula involving the right internal mammary artery, thymic, and second intercostal veins was diagnosed with selective angiography. An attempt at embolization of the fistula failed. Therefore, ligation and excision of the fistula was carried out. The etiology was attributed to parasternal wire placement during closure of the median sternotomy.

Report of 37 patients with traumatic rupture of the thoracic aorta.

The records of 37 patients with ruptured thoracic aorta were reviewed. Twenty-six were operated on, and 11 died before they could reach the operating room. Three patients died in the postoperative period: one of massive pulmonary contusion, one of pulmonary insufficiency secondary to fat emboli, and one of massive central nervous system damage. The operative complication of most concern was the anterior spinal syndrome, which occurred in three patients. Twenty-three patients survived with no sequelae from their aortic injury.

Gas pocket causing pacemaker malfunction.

Pacemaker malfunction was attributed to the increase in impedance to current flow caused by a pocket of air separating the anodal contact plate of a unipolar generator from the overlying skin. Lack of capture was noted 20 hours after implantation. The malfunction was permanently corrected by bedside aspiration of the gas with a sterile syringe.

Mediastinal teratoma masquerading as idiopathic enlargement of the right atrium.

A chest roentgenogram of an asymptomatic 22-year-old man revealed prominence of the right heart border characteristic of idiopathic dilatation of the right atrium. On further evaluation, a malignant teratoma was found. The importance of including teratoma and idiopathic enlargement of the right atrium in the differential diagnosis of abnormalities of the right heart border is discussed.

An analysis of direct and indirect measurements of left atrial filling pressure.

Left ventricular function may be assessed by direct catheter measurements of left atrial pressure or by indirect measurements of pulmonary artery wedge pressure or pulmonary artery end-diastolic pressure. Controversy exists as to how closely the indirect measurements correlate with true left atrial pressure and to which is the most accurate. To clarify this probelm, we studied 43 patients undergoing cardiac surgical procedures with cardiopulmonary bypass. Both left atrial catheters for direct measurement and Swan-Ganz catheters were placed at the time of surgery. All patients were monitored continuously for 48 hours and hourly measurements were recorded. The resultant 1,620 left atrial pressure and pulmonary artery wedge pressure figures and 1,860 left atrial pressure and pulmonary artery end-diastolic wedge pressure measurements were subjected to computer analysis. The following conclusions have been found: (1) Pulmonary artery wedge pressure is a better indirect measure of left atrial pressure than is pulmonary artery end-diastolic wedge pressure (pooled correlation coefficient 0.629); (2) direct left atrial pressure measurement is more reliable and has fewer complications than indirect measurements; (3) there is no consistent correlation between left atrial pressure and central venous pressure (pooled correlation coefficient 0.3). A discussion of our results and the problems associated with left atrial catheters and Swan-Ganz catheters is presented.