Supplemental remifentanil during coronary artery bypass grafting is followed by a transient postoperative cardiac depression.

BACKGROUND: The pharmacokinetic properties of the short-acting micro opioid receptor-agonist remifentanil makes it possible to give cardiac surgical patients a deep intraoperative anesthesia without experiencing postoperative respiratory depression and a prolonged stay in the intensive care unit (ICU). However, previous investigations have shown that patients who received remifentanil required additional analgesia during the early postoperative period as compared to patients who received fentanyl. The aim of the present study therefore was to investigate the effects of supplementing remifentanil to a standard fentanyl-based anesthesia in coronary artery bypass grafting (CABG). METHODS: The study was prospective, randomized, double-blind, and placebo-controlled. Twenty male patients aged 55-70 years were included. All patients received a standard fentanyl and isoflurane-based anesthesia. In addition, the patients were randomized to receive either remifentanil 0.5 micro g kg(-1) min(-1) or placebo during surgery. Hemodynamic recordings and measurements of blood glucose and plasma adrenaline and noradrenaline were performed intra- and postoperatively. RESULTS: Remifentanil reduced the hemodynamic and metabolic response to surgical stress compared to the standard fentanyl-based anesthetic regimen. However, the patients in the remifentanil group had a lower cardiac output (CO), left ventricular stroke work index (LVSWI), and mixed venous oxygen saturation (SvO(2)), and a higher central venous pressure (CVP) than the patients in the placebo group during the early postoperative phase, indicating a postoperative cardiac depression in the remifentanil group. CONCLUSION: In CABG, remifentanil reduces the hemodynamic and metabolic responses during surgery but seems to give a cardiac depression in the early postoperative phase.

Fewer reoperations and shorter stay in the cardiac surgical ward when stabilising the sternum with the Ley prosthesis in post-operative mediastinitis.

OBJECTIVE: Using the Ley prosthesis, a 0.5mm thick titanium alloy plate for stabilising the sternum, is a new method in the treatment of mediastinitis after open-heart surgery. We report a retrospective analysis of our experience with this device. METHODS: One hundred consecutive cases of post-operative mediastinitis in the period 1992-1997 were reviewed. The primary procedure at reoperation for infection was as follows: 52 patients were treated with the Ley prosthesis and 48 patients underwent other conventional procedures. The choice of the surgical technique depended on the attending surgeon. The prosthesis was used more frequently in patients with sternal dehiscence (P<0.001) but otherwise patients' characteristics were similar in the two groups. As a control population for outcome data, 100 uninfected patients were matched with regard to operative procedure, age, sex and date of surgery. RESULTS: The median hospital stay was 48.5 days in the mediastinitis group vs. 14 days in the control group. The all-cause 90-day mortality in the mediastinitis group was 18% vs. 5% in the control group. The 52 patients treated with the Ley prosthesis had a median length of stay in the cardiac surgery ward for 29 days vs. 41.5 days in the mediastinitis group not treated with the prosthesis (P=0.013). However, when the total length of stay including hospitals outside the cardiac surgery ward was taken into account, the prosthesis did not reduce the length of stay. Only 8/52 patients treated with the prosthesis required further surgery vs. 23/48 patients who were not primarily treated with the prosthesis (P<0.001). The Ley prosthesis had no impact on mortality. CONCLUSION: The Ley prosthesis is a valuable adjunct to the treatment of mediastinitis after open-heart surgery. A shorter stay at the cardiac surgery ward and a reduced need for further surgical procedures were observed when using this prosthesis.

Endovascular treatment of type B aortic dissections.

The purpose is to describe our experience with endovascular treatment of type B aortic dissections. Five patients were treated for complications following type B dissections like, false channel aneurysm formation, rupture and arterial obstruction. They were treated in general anaesthesia using a 'homemade' endoprosthesis or a commercially available endoprosthesis (Excluder) deployed during fluoroscopy. The patients have been followed at regular intervals with a median observation time of 18 months (range 12--36). One patient needed a secondary intervention due to dislodgement of the proximal stentgraft with haemorrhage into both the false and the true lumen. Otherwise there have been no early or late mortality or major complications in this series. Even if our experience with endovascular treatment of type B dissections is rather limited, the results so far are promising. Open surgery in many of these cases is complicated with high morbidity and mortality rate and the endovascular technique offers great advantages. A longer follow-up period is necessary to define the place of endovascular treatment.

[Mitral valve plasty. A 12-year material]. / Mitralklaffeplastikk. Et 12-årsmateriale.

46 patients underwent mitral valve repair at the Regional Hospital in Trondheim/St. Elisabeth Heart Clinic, during the period 1983-95. There were 20 female patients. The valve pathology was ischemic in 40%, rheumatic in 10% and other or unknown in 50%. The surgical technique included commissurotomy (n = 9), ring annuloplasty (n = 18), resection of posterior leaflet (n = 12), Kay annuloplasty (n = 10), shortening of chordae (n = 3) and other techniques (n = 2). Postoperative complications included wound infection (n = 1), pneumonia (n = 1), mediastinitis (n = 1), pleural effusion (n = 5), renal failure (n = 1) and multi-organ failure (n = 1). One patient required re-exploration for postoperative bleeding. Three (6.5%) patients died within 30 days of surgery due to low cardiac output (n = 2) and multi-organ failure (n = 1). Nine patients (21%) died later. At follow up, within one year of surgery, marked functional improvement was registered, with only one patient in NYHA class III and none in class IV.