Factors Associated with Safe Extubation in the Operating Room After On-Pump Cardiac Valve Surgery.

BACKGROUND: Extubation in the operating room (OR) after cardiac surgery remains controversial due to safety concerns. Its feasibility had been suggested in select patients after off-pump surgery. AIM: To review the outcomes of patients extubated in the OR after on-pump cardiac valve surgery (cohort of interest) in comparison with patients extubated conventionally in the intensive care unit (ICU) (control). We hypothesized that the timing of extubation was not associated with postoperative complications. METHODS: Retrospective review of 272 consecutive patients who had undergone cardiac valve surgery at Jackson Memorial Hospital, Miami, Florida between January 1, 2009 and December 30, 2013. RESULTS: Compared with the control group, patients extubated in the OR had shorter cardiopulmonary bypass (CPB) (87 vs. 113 min, p < 0.0001) and aortic cross-clamp times (60 vs. 78 min, p < 0.0001), lower transfusion requirements (41.38% vs. 57.01%, p = 0.0342), shorter ICU (four vs. five days, p = 0.0002), and hospital stays (7.8 vs. 10 days, p = 0.0151). Mortality, overall rates of complications in all categories, ICU readmissions, and reintubations were similar in both groups. Each additional minute of CPB decreased the odds of extubation in the OR by a factor of 0.988 (odds ratio = 0.988; 95%CI: 0.980, 0.997). Pulmonary perfusion and ventilation during CPB increased the likelihood of extubation in the OR by a factor of 2.45 (odds ratio = 2.453; 95%CI: 1.247, 4.824). CONCLUSIONS: In select patients, extubation in the OR after on-pump valve surgery is safe. It is facilitated by shorter duration of CPB and pulmonary perfusion and ventilation during CPB. doi: 10.1111/jocs.12736 (J Card Surg 2016;31:274-281).

Paradigm change in the management of patients with acute type A aortic dissection who had prior cardiac surgery.

BACKGROUND: Acute type A aortic dissection (ATAAD) is a life-threatening disease entity. Untreated, it usually results in death due to rupture of the proximal aorta into the pericardial cavity, leading to cardiac tamponade. Should patients who have had prior cardiac surgery presenting with ATAAD be treated emergently with surgery, or should they be managed medically? We herein present preliminary evidence that suggests that medical treatment, at least initially, is the best option for these patients. Surgery is indicated in the follow-up, depending on increased size of the dissection or aorta, or to prevent or treat complications. PATIENTS AND METHODS: From January 2004 to November 2009, ten consecutive male patients with prior cardiac surgery were admitted to hospital with the diagnosis of ATAAD. Mean age was 61.90 +/- 14.68 years (range, 36 to 79 years), with nine (90%) males and one (10%) female. All were treated medically as the definitive form of management. RESULTS: Mean follow-up duration was 14.62 +/- 11.12 months (range, 1 to 31 months). Overall mortality during follow-up was 20% (two patients). Eight patients (80%) are alive and well. CONCLUSIONS: This initial experience with a small, consecutive series of patients, suggests that medical treatment is an option in the initial management of patients with ATAAD who had prior cardiac surgery. It appears that emergency surgery is seldom needed. A larger series of patients and longer follow-up period are needed prior to recommending this treatment approach for such patients.

Insertion of right ventricular assist device and its removal under local anesthesia.

A patient with acute right ventricular infarction was treated with coronary artery bypass grafting. A few days later developed right ventricular failure and required insertion of a right ventricular assist device through a sternotomy approach (TandemHeart, CardiacAssist, Inc., Pittsburgh, PA, USA). We herein report a technique in which the removal of the right ventricular assist device is performed under local anesthesia without a sternotomy incision.

Pulmonary protection during cardiac surgery: systematic literature review.

Ischemia-reperfusion injury occurs during heart surgery in which cardiopulmonary bypass is used. Current knowledge of the factors contributing to postoperative pulmonary dysfunction and the measures to avoid it are reviewed.

Modified Cabrol shunt after complex aortic surgery.

Uncontrollable hemorrhage during complex aortic surgery was controlled by a new modification of the Cabrol shunt, which is reported here.