Improved Outcomes With Integrated Intensivist Consultation for Cardiac Surgery Patients.

This study examined the impact of integrated intensivist consultation in the immediate postoperative period on outcomes for cardiac surgery patients. A retrospective cohort study was conducted in 1711 adult cardiac surgery patients from a single quaternary care center in Minnesota. Outcomes were compared across 2 consecutive 2-year time periods reflecting an elective intensivist model (n = 801) and an integrated intensivist model (n = 910). Patients under the 2 models were comparable with respect to demographics, comorbidities, procedure types, and Society for Thoracic Surgery predicted risk of mortality score; however, patients in the earlier cohort were slightly older and more likely to have chronic kidney disease ( P = .003). Integrated intensivist involvement was associated with reduced postoperative ventilator time, length of stay (LOS), stroke, encephalopathy, and reoperations for bleeding (all P < .01) but was not associated with mortality. Intensivist integration into the postoperative care of cardiac surgery patients may reduce ventilator time, LOS, and complications but may not improve survival.

Aortic Root Reconstruction with a New Dacron Graft Featuring Prefabricated Coronary Side Branches: Lessons Learned from the Cabrol Procedure.

BACKGROUND: Coronary button reimplantation can represent a technical challenge of aortic root reconstruction that can be associated with significant morbidity and mortality. With the goal of simplifying coronary reimplantation and reducing the incidence of related complications, we designed a new Dacron graft with prefabricated coronary branches to minimize coronary artery mobilization and prevent the potential mechanical complications of reattachment to the body of the graft. METHODS: Between June 2010 and May 2012, we implanted the graft in eight patients (six males, two females) ranging in age from 42-68 years (mean, 54 years). Six procedures were modified Bentall reconstructions, and two procedures were valve-sparing root replacements using the reimplantation technique. RESULTS: There were no complications and no morbidity or mortality related to coronary reattachment. All patients were alive and doing well at a mean follow-up of 26 months (range, 17-38 months). At an extended mean follow-up of 42 months (range, 25-56 months), one patient died of stroke-related complications. No radiologic or clinical evidence of impairment of coronary perfusion was identified in any patient. CONCLUSIONS: The use of this new graft model may simplify the technique of root reconstruction and potentially lower the incidence of mechanical complications related to coronary button reimplantation.

Current Status of Catheter-Based Treatment of Mitral Valve Regurgitation.

PURPOSE OF REVIEW: This review examines the current status of catheter-based repair and replacement for mitral valve disease, with a focus on native primary and secondary mitral valve regurgitation. RECENT FINDINGS: Transcatheter mitral valve repair with the MitraClip®, with >40,000 performed procedures worldwide, has significantly advanced the field of transcatheter therapy for mitral valve regurgitation. Transcatheter mitral valve replacement remains in the early stages of development, mainly due to the complex anatomy and physiology of the mitral valve. Early feasibility studies in high-risk patients show promising procedural success, yet the adverse events require further study. Transcatheter therapies for mitral valve disease are the next endeavor for the pioneers of percutaneous structural heart disease interventions. Early results are encouraging but also show that further rigorous study is needed to determine efficacy and safety.

Technique of aortic root reconstruction using a new model of Dacron graft with prefabricated coronary branches.

Aortic root reconstruction is a demanding surgical procedure still associated with a significant morbidity. Arguably, the most demanding aspect of the operation is reestablishing continuity between the prosthetic graft replacing the aortic root and the coronary arteries. With the objective of simplifying the possible challenges of coronary reimplantation, we designed a new model of aortic root graft with prefabricated coronary branches. We used this technique in 8 patients (6 males, 2 females; mean age, 54 years). There were 6 modified Bentall procedures and 2 valve-sparing root replacements with the "reimplantation" technique. There was no mortality or morbidity related to the use of this new prosthetic graft. Our purpose was to report in detail the technique of aortic root reconstruction using this new graft with prefabricated coronary branches. The use of this graft may simplify the procedure and offer a valuable tool for aortic root reconstruction in cases where the reimplantation of the coronary buttons may represent a technical challenge.

Risk factors and outcomes of pancreatitis after open heart surgery.

BACKGROUND: We sought to analyze the risk factors and natural history associated with post-cardiac surgery acute pancreatitis. METHODS: Retrospective analysis of all patients having undergone cardiac surgery at our hospital between January 1, 1992, and October 1, 2001. RESULTS: A total of 10,249 cardiac operations were performed. Thirty-nine (0.4%) patients developed postoperative pancreatitis. There was a higher incidence during the period spanning 1992 through 1996 than 1997 through 2001 (0.6% versus 0.2%, P< .05). Patients with pancreatitis had longer postoperative length of stay (51+/-5 days versus 10+/-1 days, P<.05) and a greater in-hospital mortality rate (28% versus 4%, P<.05) than patients who did not develop pancreatitis. A history of alcohol abuse, cardiac surgery performed during 1992 to 1996, increased cardiopulmonary bypass time, and increased cross-clamp time were independent risk factors for the development of pancreatitis. Multiple-organ failure was an independent predictor for death among patients with pancreatitis. CONCLUSIONS: Although the frequency of post-cardiac surgery pancreatitis is diminishing, it is still associated with significant mortality.

Glucagon-like peptide 2 is an endogenous mediator of postresection intestinal adaptation.

BACKGROUND: After massive small bowel resection, the remnant intestine undergoes compensatory adaptation. We tested the hypothesis that glucagon-like peptide-2 (GLP-2) is an endogenous mediator of postresection intestinal adaptation. METHODS: Rats were allocated to 1 of 4 groups: groups 1 and 2 rats underwent mid-small bowel transection and reanastomosis; groups 3 and 4 rats underwent 75% mid-small bowel resection and reanastomosis. Groups 2 and 4 rats were administered 1.8 mg of antirat GLP-2 antibody twice daily beginning immediately after the surgical procedure; groups 1 and 3 rats were administered rabbit serum (control). Ileal specimens were harvested on postoperative day 7. RESULTS: Ileal mucosa from group 3 animals displayed morphologic and proliferative indices of adaptation. Each of these indices of adaptation was inhibited by GLP-2 immunoneutralization (group 4). Morphologic and proliferative parameters in the ileum from animals that had undergone transection with reanastomosis were unaffected by GLP-2 immunoneutralization. CONCLUSIONS: These results suggest that GLP-2 is an endogenous mediator of postresection intestinal adaptation.

Fibronectin-induced COX-2 mediates MMP-2 expression and invasiveness of rhabdomyosarcoma.

Although accumulating evidence suggests the importance of cyclooxygenase-2 (COX-2) and prostaglandin E(2) (PGE(2)) in the pathogenesis of many cancers, the mechanism by which this enzyme and its metabolite promote cancer progression is unknown. In this study, we investigated the role of COX-2 in fibronectin-induced up-regulation of rhabdomyosarcoma matrix metalloproteinase (MMP)-2 activity and cellular invasiveness. We tested three human rhabdomyosarcoma cell lines: RMS559, RD, and SJRH30. Cell attachment to fibronectin up-regulated both COX-2 expression and PGE(2) production and concomitantly enhanced MMP-2 activity. Exogenous PGE(2) stimulated MMP-2 promoter activity, increased MMP-2 expression, and increased cellular invasiveness. Aspirin and rofecoxib (non-selective and selective COX-2 inhibitor, respectively) each abolished fibronectin-associated induction of MMP-2 and induced dose-dependent reductions in cellular invasiveness. These data implicated a role for inducible COX-2 and PGE(2) in the regulation of rhabdomyosarcoma cellular invasiveness and MMP-2 activity.

Robotic mammary takedown and off-pump bypass surgery for single-vessel disease of the left anterior descending coronary artery.

Robotic takedown of the left internal mammary artery and direct off-pump anastomosis to the left anterior descending artery through small thoracotomy incisions can be done safely with minimal morbidity and is associated with decreased blood loss, decreased ventilatory requirements, less intensive care unit stay, and less overall length of stay. It should be considered as an alternative to percutaneous angioplasty and stenting for those with isolated left anterior descending artery disease.

Liberal use of delayed sternal closure for postcardiotomy hemodynamic instability.

BACKGROUND: The purpose of this retrospective study was to evaluate the current incidence, survival, and predictors of mortality for open chest management at our center. METHODS: Our database was analyzed to identify adult postcardiotomy patients who left the operating room without primary sternal closure. Medical records were reviewed to determine mortality, postoperative complications, and pertinent hemodynamic data. RESULTS: From November 1997 to June 2000, 5,177 adults underwent cardiac procedures at our center. The incidence of open chest management was 1.7% (87 of 5,177), including 0.7% (16 of 2,254) for isolated coronary artery bypass grafting, 1.6% (15 of 912) for isolated valve, and 5.6% (47 of 839) for combined valve/coronary bypass. Hospital survival was 76% (66 of 87). Major complications included deep sternal infection (n = 4), stroke (n = 8), and dialysis (n = 13). Predictors of mortality by univariate analysis included ventricular assist device insertion (p = 0.003), new onset hemodialysis (p < 0.0005), reoperation for bleeding (p = 0.002), sternal infection (p = 0.042), mean length of delay before sternal closure (survivors = 3.2 days, nonsurvivors = 6.2 days; p = 0.031), higher mean dose of epinephrine at the time of chest closure (2.5 microg versus 0.9 microg, p = 0.011), and longer duration of high dose inotropic therapy (110 hours versus 43 hours, p = 0.002). Multivariate analysis showed ventricular assistance and reoperation for bleeding as independent predictors of in-hospital death with odds ratios of 3.8 and 3.4, respectively. CONCLUSIONS: Liberal use of open chest management is useful in patients with postcardiotomy shock, and can be carried out with a relatively low incidence of sternal complications. Patients who require ventricular assistance or exploration for ongoing mediastinal bleeding continue to have a high mortality rate.