Randomized Study Comparing the Effect of Carbon Dioxide Insufflation on Veins Using 2 Types of Endoscopic and Open Vein Harvesting.

OBJECTIVE: The aim of the study was to assess whether the use of carbon dioxide insufflation has any impact on integrity of long saphenous vein comparing 2 types of endoscopic vein harvesting and traditional open vein harvesting. METHODS: A total of 301 patients were prospectively randomized into 3 groups. Group 1 control arm of open vein harvesting (n = 101), group 2 closed tunnel (carbon dioxide) endoscopic vein harvesting (n = 100) and Group 3 open tunnel (carbon dioxide) endoscopic vein harvesting (open tunnel endoscopic vein harvesting) (n = 100). Each group was assessed to determine the systemic level of partial arterial carbon dioxide, end-tidal carbon dioxide, and pH. Three blood samples were obtained at baseline, 10 minutes after start of endoscopic vein harvesting, and 10 minutes after the vein was retrieved. Vein samples were taken immediately after vein harvesting without further surgical handling to measure the histological level of endothelial damage. A modified validated endothelial scoring system was used to compare the extent of endothelial stretching and detachment. RESULTS: The level of end-tidal carbon dioxide was maintained in the open tunnel endoscopic vein harvesting and open vein harvesting groups but increased significantly in the closed tunnel endoscopic vein harvesting group (P = 0.451, P = 0.385, and P < 0.001). Interestingly, partial arterial carbon dioxide also did not differ over time in the open tunnel endoscopic vein harvesting group (P = 0.241), whereas partial arterial carbon dioxide reduced significantly over time in the open vein harvesting group (P = 0.001). A profound increase in partial arterial carbon dioxide was observed in the closed tunnel endoscopic vein harvesting group (P < 0.001). Consistent with these patterns, only the closed tunnel endoscopic vein harvesting group demonstrated a sudden drop in pH over time (P < 0.001), whereas pH remained stable for both open tunnel endoscopic vein harvesting and open vein harvesting groups (P = 0.105 and P = 0.869, respectively). Endothelial integrity was better preserved in the open vein harvesting group compared with open tunnel endoscopic vein harvesting or closed tunnel endoscopic vein harvesting groups (P = 0.012) and was not affected by changes in carbon dioxide or low pH. Significantly greater stretching of the endothelium was observed in the open tunnel endoscopic open tunnel endoscopic vein harvesting group compared with the other groups (P = 0.003). CONCLUSIONS: This study demonstrated that the different vein harvesting techniques impact on endothelial integrity; however, this does not seem to be related to the increase in systemic absorption of carbon dioxide or to the pressurized endoscopic tunnel. The open tunnel endoscopic harvesting technique vein had more endothelial stretching compared with the closed tunnel endoscopic technique; this may be due to manual dissection of the vein. Further research is required to evaluate the long-term clinical outcome of these vein grafts.

Innovative use of the octopus stabilizer in the excision of a cardiac hydatid cyst.

Hydatid disease is caused through Echinococcus granulosus infection. Hydatid disease remains endemic in developing countries. The majority of cases involve the lungs or liver. We report the case of a patient diagnosed with concurrent mediastinal and cardiac cysts. In this patient, the Octopus IV cardiac stabilizer was used to rotate the heart after the excision of the mediastinal cyst, enabling the excision of a cyst adherent to left ventricle through a single median sternotomy incision. To date, there have been no reports of the application of the Octopus IV cardiac stabilizer in such a way.

A randomized study comparing traditional monofilament knotted sutures with barbed knotless sutures for donor leg wound closure in coronary artery bypass surgery.

OBJECTIVES: Surgical knots on the suture line provide an anchoring function, but also represent a potential source of infection and irritation on the donor leg after coronary artery bypass surgery. Knotless barbed sutures were designed to prevent knot-related complications. This study compared knot-related wound complication rates between patients receiving traditional monofilament sutures and those receiving barbed knotless sutures for closure of the donor leg. METHODS: One hundred and forty-two patients were randomized into two groups. Group 1 (n = 70) received traditional monofilament sutures and Group 2 (n = 72) received barbed knotless sutures. All wounds were assessed on postoperative days 3 and 5 and weeks 2, 4 and 6 using a validated wound scoring system. Antibiotics usage and general practitioner and district nurse visits were recorded. RESULTS: No demographic differences were observed between groups. Leg wound skin closure times were significantly shorter in Group 2 compared with Group 1 (P < 0.001). Group 1 demonstrated a greater incidence of excessive scarring (P < 0.001), itching (P < 0.001), irritation (P < 0.001) and adverse skin tissue reactions (P < 0.001) than Group 2. Fewer general practitioner visits were recorded in Group 1 compared with Group 2 (P = 0.051). CONCLUSION: Knotless barbed suture usage significantly reduces the incidence of knot-related leg wound complications compared with traditional monofilament knotted sutures. This may be related to differences in the rate of absorption of the suture material or an associated decrease in the incidence of adverse skin tissue reactions that may delay postoperative wound healing.

Does the introduction of a comprehensive structured training programme for endoscopic vein harvesting improve conduit quality? A multicentre pilot study.

OBJECTIVES: Endoscopic vein harvesting is one of the most popular minimally invasive vein-harvesting techniques for coronary artery bypass graft surgery. It is associated with improved cosmetic outcome and fewer wound-related problems compared with the conventional open technique. However, its efficacy with regard to conduit damage and long-term patency has recently been questioned. Learning curve-associated trauma to the vein has a major impact on vein quality and the incidence of graft failure post-surgery. In an attempt to address this problem, we have devised and tested a learning tool termed Manchester Endoscopic Learning Tool (MELT). In this study, we compare vein quality following MELT training with standard recommended training. METHODS: Fourteen practitioners across seven UK centres were enrolled into the study. Practitioners were categorized into two groups receiving MELT or standard training. Data were collected prospectively from the first eight vein retrievals per operator following training. A total of n = 112 vein-harvesting procedures were included in the study. RESULTS: Veins harvested by MELT practitioners had fewer small avulsions (P <0.001), required fewer repairs (P <0.001) and experienced a lower incidence of bruising (P <0.001) than veins obtained by practitioners receiving standard training. The incidence of very short side branches requiring repair was also significantly reduced (P <0.001) in the MELT group compared with standard training. CONCLUSIONS: Our formalized training programme consistently minimizes vein trauma resulting in better-quality conduits when compared with the current standard training. Exposure of surgical practitioners to the structured curriculum during their endoscopic vein harvesting training will enhance their learning and lead to better-quality conduits. This is likely to impart clinical benefit post-surgery.

Heart transplantation in patients with eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome).

BACKGROUND: Heart involvement is the leading cause of death of patients with eosinophilic granulomatosis with polyangiitis (EGPA; formerly Churg-Strauss syndrome) and is more frequent in anti-neutrophil cytoplasm antibody (ANCA)-negative patients. Post-transplant outcome has only been reported once. METHODS: We conducted a retrospective international multicenter study. Patients satisfying the criteria of the American College of Rheumatology and/or revised Chapel Hill Consensus Conference Nomenclature were identified by collaborating vasculitis and transplant specialists, and the help of the Churg-Strauss Syndrome Association. RESULTS: Nine ANCA(-) patients who received transplants between October 1987 and December 2009 were identified. The vasculitis and cardiomyopathy diagnoses were concomitant for 5 patients and separated by 12 to 288 months for the remaining 4 patients. Despite ongoing immunosuppression, histologic examination of 7 (78%) patients' explanted hearts showed histologic patterns suggestive of active vasculitis. The overall 5-year survival rate was low (57%), but rose to 80% when considering only the 6 patients transplanted during the last decade. After survival lasting 3 to 60 months, 4 (44%) patients died sudden deaths. CONCLUSIONS: The search for EGPA-related cardiomyopathy is mandatory early in the course of this type of vasculitis. Indeed, prompt treatment with corticosteroids and cyclophosphamide may achieve restore cardiac function. Most patients in this series were undertreated. For patients with refractory EGPA, heart transplantation should be performed, which carries a fair prognosis. No optimal immunosuppressive strategy has yet been identified.

Can the temporary use of right ventricular assist devices bridge patients with acute right ventricular failure after cardiac surgery to recovery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Can the temporary use of right ventricular assist devices (RVADs) bridge patients to recovery who suffer acute right ventricular failure after cardiac surgery? More than 183 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. Indications for surgical intervention included coronary artery bypass surgery, valve replacement, post-heart transplant and left ventricular assist device insertion. Significant reductions in central venous pressure (P = 0.005) and mean pulmonary artery pressures (P < 0.01) were reported during and after RVAD support. Furthermore, increases in right ventricular cardiac output (P < 0.05), right ventricular ejection fraction (P < 0.05), right ventricular stroke work (P < 0.05) and pulmonary artery oxygen saturations (P < 0.05) were also seen. Assessment by one study showed that on Day 7 after RVAD removal, the right ventricular ejection fraction had increased by up to 40%. Dynamic echocardiography studies performed before, during and after RVAD placement demonstrated that after RVAD implantation, right ventricular end-diastolic dimensions (P < 0.05) and right atrial dimensions decreased (P < 0.05) and right ventricular ejection fraction (P < 0.05) increased. Although several studies successfully weaned patients from an RVAD, there were several complications, including bleeding requiring surgical intervention. However, this may be reduced by using percutaneous implantation (bleeding incidence: 4 of 9 patients) rather than by a surgically implanted RVAD (bleeding incidence: 5 of 5 patients). However, mortality is higher in percutaneous RVAD patients rather than in surgical RVAD (80-44%) patients. Causes of death cited for patients on an RVAD included multiorgan failure, sepsis, thromboembolic events, reoccurring right heart failure and failure to wean due to persistent right ventricular failure. We conclude that RVADs have been successfully used to bridge patients to recovery after cardiac surgery; however, RVADs carry numerous risks and a high mortality rate.

A pilot project of familial screening in patients with bicuspid aortic valve disease.

BACKGROUND AND AIM OF THE STUDY: Bicuspid aortic valve (BAV) is a common congenital cardiac abnormality, is often familial, and is associated with dilatation of the aortic root. The risk of dissection is significantly higher than that in the general population, occurring at a younger age than in patients with idiopathic aortic aneurysms. Current ACC/AHA guidelines recommend familial echocardiographic screening which, to the present authors' knowledge, is not performed routinely and uniformly. The aim of this pilot project was to explore the practicalities of running such a program. METHODS: An initial cohort of 47 patients who had undergone surgery for BAV disease and/or associated aneurysmal aortic dilatation were offered counseling and familial screening. Referred first-degree relatives (FDR) underwent aortic valve and root assessment by standard two-dimensional echocardiography. RESULTS: Twenty-four index patients (51%) referred a total of 75 FDR (approximately three per patient) who wished to undergo echocardiography, of whom 52 (70%) attended for review. The pick-up rate of newly detected BAV was 8% (four of 52 relatives). One of these asymptomatic individuals had a significant ascending aortic aneurysm, which required prompt surgery. In the families of the 24 index patients, there was a total of eight cases (14% prevalence) of aortic valve disease, either known or newly detected via screening. CONCLUSION: This pilot study confirmed the relatively high prevalence of BAV among FDR of patients who have undergone surgery for BAV-associated pathology. Patients should be made aware of the condition's pattern of inheritance, and familial screening should be actively pursued to reduce the potential morbidity and mortality associated with BAV and its related aortopathy. A number of important and practical considerations for setting-up a familial screening program are discussed.

Does the use of thiopental provide added cerebral protection during deep hypothermic circulatory arrest?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Does the use of thiopental provide added cerebral protection during deep hypothermic circulatory arrest (DHCA)? Altogether, more than 62 papers were found using the reported search, of which 7 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. Four of the seven papers used thiopental alongside other neuroprotective methods and agents. The methods included the use of ice packs to the head and core systemic hypothermia. Agents used alongside thiopental included nicardipine and mannitol. Thiopental was found to have the ability to lower oxygen consumption, where oxygen consumption was measured using the phosphocreatinine and adenosine triphosphate ratio. The neuroprotective effect of thiopental was evaluated by assessing the electrical activity of the brain during circulatory arrest, by which it was shown to be advantageous. However, other trials suggested that adding thiopental during circulatory arrest did not provide any extra protection to the brain. The timing of thiopental administration is of importance in order to gain positive outcomes, as it's ability to lower the cerebral energy state may result in unfavourable results if added before hypothermic circulatory arrest, where this may lead to an ischaemic event. We conclude that the use of thiopental during deep hypothermic circulatory arrest is beneficial, but if administered too early, it may replete the cerebral energy state before arrest and prove to be detrimental.

Does retraction of the sternum during median sternotomy result in brachial plexus injuries?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'does retraction of the sternum during median sternotomy result in brachial plexus injuries or peripheral neuropathies?' Altogether 58 papers were found using the reported search, of which 12 represented the best evidence to answer the question. The authors, date, journal and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Caudal placement of the retractor or relieving the pressure superiorly by removing the upper blades of a retractor (P = 0.02) and use of a caudally placed symmetrical retractor has been shown to reduce neuropathy. Positioning of the patient with 'hands up' positioning showed significant reduction in the incidence of brachial plexus injuries. Furthermore, how wide the retractor is opened and use of an asymmetrical retractor for internal mammary artery (IMA) harvesting are also important factors in quantifying risk of postoperative neuropathy. Wider sternal retraction and longer bypass time did increase the risk of developing postoperative neuropathy. Three asymmetrical retractors were looked at that demonstrates the Delacroix-Chevalier to be the safest (P < 0.05). We conclude that median sternotomy risks brachial plexus injury and where possible the sternum should be opened as small a distance as possible with symmetrical retractor and using a caudally placed retractor.

Is cerebrospinal fluid drainage of benefit to neuroprotection in patients undergoing surgery on the descending thoracic aorta or thoracoabdominal aorta?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Is cerebrospinal fluid (CSF) drainage of benefit in patients undergoing surgery on the descending thoracic aorta or thoracoabdominal aorta?' Altogether 1177 papers were found using the reported search, of which 17 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. Ten of 13 studies demonstrate significant neurological protection from CSF drainage (± additional adjuncts), with two further papers showing no significant difference between patients who had or had not had CSF drainage and one study unable to provide any conclusions. For patients having surgery on the thoracic aorta or thoracoabdominal aorta CSF drainage, maintaining pressures <10 mmHg (P < 0.03), in conjunction with other neuroprotective strategies, minimizes the risk of neurological sequelae when compared with patients treated with similar adjuncts but without CSF drainage. The majority of studies used additional neuroprotective strategies, including cooling and reattachment of the intercostal arteries as adjuncts to CSF drainage. Logistic regression curves demonstrated that the longer the ischaemia time, the greater the benefit from CSF drainage (P < 0.04). Four papers observed complications of CSF drainage, of which the main complications were: catheter occlusion or dislodgement, headache, meningitis and subdural haematoma. Overall, CSF drainage does offer a neuroprotective benefit; preventing paraplegia if CSF pressures are maintained <10 mmHg.

Is it worth packing the head with ice in patients undergoing deep hypothermic circulatory arrest?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Is it worth packing the head with ice in patients undergoing deep hypothermic circulatory arrest (DHCA)? Altogether more than 34 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question, 5 of which were animal studies, 1 was a theoretical laboratory study and 1 study looked at the ability to cool using circulating water 'jackets' in humans. There were no available human studies looking at the neurological outcome with or without topical head cooling with ice without further adjunct methods of cerebral protection. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Four papers studied animals undergoing DHCA for 45 min-2 h depending on the study design, with or without packing the head with ice. The studies all demonstrated improved cerebral cooling when the head was packed with ice during DHCA. They also illustrated an improved neurological outcome, with better behavioural scores (P < 0.05), and in some, survival, when compared with animals whose heads were not packed in ice. One study examined selective head cooling with the use of packing the head with ice during rewarming after DHCA. However, they demonstrated worse neurological outcomes in these animals, possibly due to the loss of cerebral vasoregulation and cerebral oedema. One study involved a laboratory experiment showing improved cooling using circulating cool water in cryotherapy braces than by using packed ice. They extrapolated that newer devices to cool the head may improve cerebral cooling during DHCA. The final study discussed here demonstrated the use of circulating water to the head in humans undergoing pulmonary endarterectomy. They found that tympanic membrane temperatures could be maintained significantly lower than bladder or rectal temperatures when using circulating water to cool the head. We conclude that topical head cooling with ice is of use during DHCA but not during rewarming following DHCA and that it may be possible to advance topical head cooling techniques using circulating water rather than packed ice.

A randomized study comparing three groups of vein harvesting methods for coronary artery bypass grafting: endoscopic harvest versus standard bridging and open techniques.

OBJECTIVES: The use of an open vein harvesting (OVH) technique for saphenous vein harvesting (SVH) is associated with wound complications and delayed patient mobilization. This has led to the development of minimally invasive vein harvesting (MIVH) techniques, such as standard bridging and endoscopic SVH (EVH). This randomized trial was established to assess immediate clinical outcome and patient satisfaction in our centre. METHODS: A total of 150 consecutive patients were prospectively randomized into three groups. Group 1 consisted of 50 patients who underwent OVH, Group 2 consisted of 50 patients who underwent a standard bridging technique (SBT) and Group 3 consisted of 50 patients who underwent EVH. Each group was assessed for the incidence of wound infection, postoperative pain and satisfaction and the number of vein repairs using previously validated scoring systems. RESULTS: The MIVH techniques reduced the pain at hospital (P < 0.001) and at 6 weeks (P < 0.001), and improved cosmesis (P < 0.001), compared with the OVH group. Patient satisfaction was greatest in the EVH group followed by the SBT and then the OVH group. The clinical markers of inflammation were reduced with an MIVHt. There were more vein repairs in the EVH compared with the OVH (P < 0.001) and the SBT (P = 0.04) groups. CONCLUSIONS: This study demonstrates that MIVH reduces wound morbidity. We believe that each technique has advantages and disadvantages, which should be considered during the selection of a harvesting procedure by both the patient and the surgeon.

Closed suction drainage improves clinical outcome in patients undergoing endoscopic vein harvesting for coronary artery bypass grafting.

BACKGROUND: Endoscopic vein harvesting (EVH) is a widely accepted technique for coronary artery bypass grafting, with well-reported benefits. However, EVH is associated with severe hematoma formation at incision sites, resulting in postoperative pain. We hypothesized that the use of a leg wound drain at the incision site may reduce these comorbidities. METHODS: One hundred consecutive patients were prospectively randomly allocated into two groups of 50: group 1 with leg wound drains, and group 2 without drains. Group 1 patients underwent EVH followed by closure with a size 10 high vacuum leg wound drain (20 kPa), whereas group 2 underwent EVH followed by closure without a leg wound drain. Patients were assessed for postoperative pain, wound infection, and satisfaction using validated scoring systems immediately after surgery. RESULTS: Pain at rest (p < 0.001) and with movement (p < 0.001), incidence of hematoma (p < 0.001), and patient satisfaction (p < 0.001) were significantly improved in the drain group at days 1 to 7 and remained significant at week 6 after surgery. Interestingly, the use of antibiotics (6% versus 24%, p = 0.012) and the number of general practitioner visits (6% versus 26%, p = 0.012) were lower in the drain group compared with the no-drain group. However, there were no differences in the length of hospital stay between the two groups after surgery. CONCLUSIONS: Our findings indicate that the use of a high vacuum leg drain after EVH for long saphenous vein is of clear therapeutic benefit in the early postoperative period. We also report that this technique may reduce antibiotic administration and general practitioner visits after patient discharge.

Scrotal distension after endoscopic harvesting of the saphenous vein in patients with inguinal hernia.

The great saphenous vein remains the most commonly used conduit for coronary artery bypass grafting. The endoscopic vein harvesting technique is widely used due to reduced postoperative complications. We present the case of 5 patients with a history of inguinal hernia undergoing coronary artery bypass grafting, which resulted in CO2 infiltration through the deep inguinal ring and into the scrotum leading to acute scrotal enlargement. Due to the risk of impediment of vascular blood supply and necrosis, endoscopic vein harvesting was withdrawn, and the vein was harvested by using the bridging technique. Postoperatively, severe contusion, inflammation, and erythematous vesicular eruption resulted in a lengthened hospital stay.

Inpatient Oral Anticoagulation Management by Clinical Pharmacists: Safety and Cost effectiveness.

BACKGROUND: Warfarin prescription for anticoagulation after cardiac surgery has always been a challenge for junior medical staff. METHODS: A prospective study was carried out to assess the quality of anticoagulation control by junior doctors compared with clinical pharmacists at South Manchester University hospitals NHS Trust. The junior medical staff prescribed warfarin for 50 consecutive patients from April to September 2006 (group A, n = 50) and experienced clinical pharmacists dosed 46 consecutive patients between February and May 2007 (group B, n = 46). RESULTS: In group A, 9 (18%) patients discharge was delayed because of lack of attainment of therapeutic International Normalised Ratio (INR) compared to 3 (6.5%) in group B. The total number of bed days resulting from the delay in group A was 21 compared to 4 in group B. Extrapolated over a year this would amount to approximately 15,750 extra cost incurred in group A opposed to 3000 in group B. CONCLUSIONS: The pharmacists were significantly better than junior doctors in achieving therapeutic INR, resulting in fewer discharge delays. The clinical pharmacists with experience in outpatient anticoagulation clinic can play an important role in inpatient oral anticoagulation management in post cardiac surgery patients thereby providing improved cost effective quality of care. KEYWORDS: Warfarin; Pharmacist; Management.

A comparative analysis of saphenous vein conduit harvesting techniques for coronary artery bypass grafting--standard bridging versus the open technique.

Coronary artery bypass graft (CABG) surgery involves harvesting the great saphenous vein (GSV) using the traditional open technique (TOT). This can be associated with significant leg morbidity and patient dissatisfaction. Alternatively, the standard bridging technique (SBT) is a minimally invasive procedure of vein retrieval that uses smaller frequent incisions along the length of the leg and may reduce postoperative complications. This study was designed to compare the success of SBT in reducing leg morbidity and increasing patient satisfaction. One hundred patients were recruited into the study and computer randomised into two groups of 50 undergoing SBT or TOT. Leg morbidity and patient satisfaction were analysed by assessment of pain scores, wound development and scar formation. Closure and harvesting time were also compared between the two groups. SBT was associated with better wound development (P<0.001) and a significantly higher patient satisfaction (P<0.001). Leg pain was significantly reduced amongst SBT group at rest and with movement (P<0.001). There was also a reduction in saphenous neuropathy with the use of SBT (P<0.001). No difference in closure or harvesting time was demonstrated (P=0.26 and P=0.23, respectively). This study demonstrates that harvesting the GSV by the minimally invasive SBT reduces postoperative leg morbidity and increases patient satisfaction without the need of costly equipment. SBT represents a safe, effective and financially viable technique for vein harvesting.

Randomized prospective study comparing conventional subcuticular skin closure with Dermabond skin glue after saphenous vein harvesting.

BACKGROUND: Dermabond (Ethicon UK, Edinburgh, United Kingdom) is a topical skin adhesive used for surgical wound closure, with purported advantages over conventional sutures on cosmetic outcomes, cost benefits, and operative times. This study compared results of skin closure using Dermabond and subcuticular sutures after coronary artery bypass grafting (CABG). METHODS: The study prospectively enrolled and randomized 106 patients who underwent CABG. The groups received closure with Dermabond skin glue or subcuticular sutures (n = 53 each) after saphenous vein harvesting using the bridging technique. Wound closure time for the two methods was recorded. Cosmetic appearance was assessed using the Hollander, the Vancouver, and the visual analog scale. Patient satisfaction was recorded before discharge and at week 6. RESULTS: There were no significant differences in the total operative time between the two groups (p = 0.43). Closure time was significantly shorter in the Dermabond group (p = 0.017). Patients in the Dermabond group also reported superior cosmetic outcome at weeks 1 (p < 0.001) and 6 (p = 0.001) and improved patient satisfaction (p < 0.001). CONCLUSIONS: Dermabond has demonstrated superiority over traditional subcuticular skin sutures in terms of closure time, cosmetic appearance, and patient satisfaction. This technique provides a novel method of wound closure after CABG.

Chylopericardium after cardiac surgery can be treated successfully by oral dietary manipulation: a case report.

We report a case of chylopericardium after ascending aorta and aortic valve replacement, which presented as late tamponade. We discuss the various treatment options in this rare condition which can result in serious morbidity or death.

Factors which influence the cardiac surgeon's decision not to operate on patients referred for consideration of surgery.

BACKGROUND: The aim of this study was to document what proportion of patients referred for consideration of cardiac surgery are turned down, the reasons given for not operating and also to evaluate what happens to those patients who do not undergo surgery. METHODS: 382 elective patients referred for consideration of cardiac surgery to one of six consultant cardiac surgeons at Wythenshawe Hospital during a one year period from were included in the study. Data for those patients who underwent an operation were collected prospectively in a cardiac surgery database. The case notes of those patients who did not undergo an operation were reviewed to establish reasons given by surgeons for not operating. Patients were followed up to determine vital status at the end of the study period. RESULTS: 333 (87.2%) patients underwent an operation and 49 (12.8%) did not. 68% of patients turned down were thought to be too high-risk. 14% of patients did not fulfill symptomatic or prognostic criteria for surgery and in 8% of patients coronary artery surgery was thought ineffective due to poor distal vessels. 6% of patients declined an operation and 4% were thought to be more suitable for coronary angioplasty. Patients turned down for surgery had more renal dysfunction (p = 0.017), respiratory disease (p < 0.001) and peripheral vascular disease (p < 0.001), were more likely to have undergone prior heart surgery (p < 0.001) and to have poor left ventricular function (p = 0.003). Patients turned down for surgery had significantly higher EuroSCORE values compared to patients who underwent an operation: 5 versus 4 (p = 0.006). Freedom from death in the patients turned down for surgery at 1-, 6-, 12- and 24-months was 95.9%, 91.8%, 83.7% and 71.4% respectively, compared with 97.9%, 96.7%, 96.4% and 94.5% for the patients who underwent an operation (p < 0.001 [log-rank]). 14 of the 15 deaths that occurred in the turned down group occurred in the category considered too high-risk for surgery. CONCLUSION: 12.8% of patients referred for consideration of cardiac surgery did not undergo an operation. Two thirds of patients not accepted for surgery were thought too high risk. Those patients who did not undergo an operation had a significantly worse mortality.