Diabetes management during cardiac surgery in the UK: A survey.

AIM: To determine current practice regarding the diabetes management of people undergoing cardiac surgery in the UK. METHODS: We conducted an online survey of UK cardiothoracic surgeons. All cardiothoracic surgeons listed in the Society of Cardiothoracic Surgery membership directory were invited to participate. The survey, compiled using SurveyMonkey software, comprised 15 closed and open-ended questions about the management of people with diabetes pre- and peri-operatively. RESULTS: Sixty-two cardiothoracic surgeons from all 33 UK cardiac centres completed the survey. Of these, 44% responded that they routinely measure HbA1c preoperatively for all patients, 19% had an HbA1c threshold above which they would not operate and 21% currently undertake a point-of-care HbA1c measurement during the cardiothoracic outpatient visit. A total of 74% of respondents reported that it was 'easy' or 'very easy' to obtain a diabetes team review; diabetes nurse specialists were the members of the diabetes team working most closely with cardiac surgeons. Up to a third of the surgeons did not provide physical activity recommendations prior to admission and over 80% did not have a different preoperative or surgical diabetes protocol. Inconsistency in the responses within centres suggests that differences in practice may depend on individual surgeons rather than local policy. CONCLUSIONS: The study demonstrates there is only limited peri-operative management of diabetes in people undergoing cardiac surgery in the UK. There is an opportunity for greater involvement of the diabetes specialist team both before and during admission for surgery to improve outcomes. (Trial registration: ISRCTN10170306).

Surgical treatment of transcatheter aortic valve infective endocarditis.

There is growing interest in infections occurring after transcatheter aortic valve implantation (TAVI). The incidence, and clinical and anatomical features suggest many similarities with prosthetic valve endocarditis. The survival of patients with an infected TAVI prosthesis is generally poor; however, only a minority of them (10%) have undergone treatment with surgical explantation of the infected prosthesis. A literature search was performed using online databases. Papers reporting surgical treatment of TAVI prosthesis infections were retrieved, focusing on pre- and intraoperative characteristics and early outcome. Thirty-seven papers ultimately provided information on 107 patients. Their mean ± standard deviation (SD) age was 76 ± 8 years and 72% were male. The mean ± SD time interval between the TAVI procedure and reoperation was 10 ± 10 months. Annular abscess formation was described in 34% of cases and mitral valve involvement in 31%. All patients underwent TAVI prosthesis explantation and surgical aortic valve replacement; concomitant mitral valve replacement was necessary in 22% of cases. Postoperative in-hospital mortality was 28%. Surgical explantation of infected TAVI prostheses was associated with a high postoperative mortality, although these initial experiences included elderly and high-risk patients. Considering the expansion of TAVI procedures towards younger and lower-risk patients, surgical treatment of TAVI endocarditis may represent the best option for a life-saving procedure.

Transapical perfusion for peri-arrest salvage during transcutaneous aortic valve implantation.

An 80-year-old man developed severe haemodynamic instability during a transapical aortic valve implantation. He was not suitable for a conventional surgical approach due to comorbidities and patent aortocoronary bypass grafts also limited further stabilizing actions. As a bail-out procedure, we demonstrate the feasibility of transapical arterial cannulation by crossing a newly implanted TAVI valve in order to establish an emergency bypass circuit.

Reliability of different body temperature measurement sites during aortic surgery.

OBJECTIVE: We retrospectively performed a comparative analysis of temperature measurement sites during surgical repair of the thoracic aorta. METHODS: Between January 2004 and May 2006, 22 patients (mean age: 63 ± 12 years) underwent operations on the thoracic aorta with arterial cannulation of the aortic arch concavity and selective antegrade cerebral perfusion (ACP) during deep hypothermic circulatory arrest (HCA). Indications for surgical intervention were acute type A dissection in 14 (64%) patients, degenerative aneurysm in 6 (27%), aortic infiltration of thymic carcinoma in 1 (4.5%) and intra-aortic stent refixation in 1 (4.5%). Rectal, tympanic and bladder temperatures were evaluated to identify the best reference to arterial blood temperature during HCA and ACP. RESULTS: There were no operative deaths and the 30-day mortality rate was 13% (three patients). Permanent neurological deficits were not observed and transient changes occurred in two patients (9%). During re-warming, there was strong correlation between tympanic and arterial blood temperatures (r = 0.9541, p<0.001), in contrast to the rectal and bladder temperature (r = 0.7654, p = n.s; r = 0.7939, p = n.s., respectively). CONCLUSION: We conclude that tympanic temperature measurements correlate with arterial blood temperature monitoring during aortic surgery with HCA and ACP and, therefore, should replace bladder and rectal measurements.

Long-term statin administration to dams on high-fat diet protects not only them but also their offspring from cardiovascular risk.

We aimed to study the effects of long-term statin administration to high fat (HF)-fed female mice from the time they were weaned through to pregnancy and lactation on cardiovascular and metabolic risk factors in their HF-fed offspring. Female C57 mice on HF (45% kcal fat) were given pravastatin in their drinking water from the time they were weaned, during pregnancy and lactation. Weaned offspring were then fed an HF diet until adulthood generating the dam/offspring dietary groups HF/HF and HF plus pravastatin from the time dams were weaned, during pregnancy and lactation/HF (HF+S/HF). These groups were compared with offspring from mothers fed standard chow (control) which were then fed a control diet up to adulthood (control/control; C/C). HF+S dams showed significantly reduced total cholesterol concentrations and systolic blood pressure (SBP) versus HF dams. The reduction in total cholesterol and SBP in the HF+S dams did not restore values to those observed in the C group. Both male and female HF+S/HF offspring were significantly lighter in weight, and had lower SBP and serum cholesterol concentrations versus HF/HF. HF/HF offspring had elevated C-reactive protein levels but HF+S/HF animals of both sexes had reduced levels similar to those found in the C/C group. Long-term pravastatin administration to dams not only protects them from the deleterious effects of an HF diet, but this long-term maternal statin protection also has an equal and permanent effect in both male and female offspring up to their adult life, which is a novel finding.

Management options for aorto-oesophageal fistula: case histories and review of the literature.

OBJECTIVE: An aorto-oesophageal fistula is a rare clinical entity, leading to life-threatening gastrointestinal bleeding. Thoracic aortic aneurysms are the most common cause of aorto-oesophageal fistulae; further causes involve foreign body ingestion, trauma (in most cases iatrogenic), carcinoma or, very rarely, aortitis tuberculotica. METHODS: Due to its rarity, there are no large multicentre studies present to evaluate the efficacy of different therapeutic management options. Since it is associated with significant morbidity and mortality, we give a short summary of various treatment approaches performed in our clinical practice in the past three years. The most straightforward therapeutic option may be an endovascular aortic repair and subtotal oesophageal resection followed by gastro-oesophageal reconstruction, but other alternative treatment possibilities are also present, although with probable higher morbidity. CONCLUSIONS: Eliminating the source of bleeding as an emergency, resecting the oesophagus urgently to prevent sepsis and reconstructing the gastrointestinal continuity as an elective case after having the inflammatory processes settled seems to justify the endovascular aortic repair and subtotal oesophageal resection, followed by a gastro-oesophageal reconstruction, as an effective surgical approach.

Unidentified retained inferior vena cava myxoma detected by intra-operative trans-oesophageal echocardiography.

We report a unilateral right atrial familial myxoma with a multicentric nature discovered during cardiac surgery. After the patient was weaned off cardiopulmonary bypass, an inferior vena cava myxoma was discovered with intra-operative trans-oesophageal echocardiogram (TOE) which had been missed preoperatively and during surgery.

Defective NOTCH signaling drives increased vascular smooth muscle cell apoptosis and contractile differentiation in bicuspid aortic valve aortopathy: A review of the evidence and future directions.

Bicuspid aortic valve (BAV) disease remains the most common congenital cardiac disease and is associated with an increased risk of potentially fatal aortopathy including aortic aneurysm and dissection. Mutations in the NOTCH1 gene are one of only a few genetic anomalies identified in BAV disease; however evidence for defective NOTCH signaling, and its involvement in the characteristic histological changes of VSMC apoptosis and differentiation in ascending aortae of BAV patients is lacking. This review scrutinizes the evidence for the interactions of NOTCH signaling, cellular differentiation and apoptosis in the context of aortic VSMCs and provides focus for future research efforts in the diagnosis of BAV aortopathy and prevention of catastrophic complications through NOTCH signaling manipulation.

Acquired segmental emphysema: the enlarging spectrum of Swyer-James/Macleod's syndrome.

Three cases of Macleod's syndrome are described, all of which required surgical resections for distressing symptoms. This provided a rare opportunity to examine the pathologic features of a condition that is usually diagnosed on its radiologic features, and the etiology of which remains unestablished. Three patients (2 women and 1 man), aged 20, 23, and 24 years, were referred from respiratory physicians because of unilateral hyperlucent lungs and associated symptoms. All 3 patients had unilateral hyperlucent lungs, but only 1 patient had demonstrable mediastinal shift on expiratory and inspiratory chest computed tomographic scan. Segmentectomies were performed (n = 4) in all the patients without perioperative morbidity or mortality. Patients have been followed up between 6 and 18 months, and remain asymptomatic with a return to normal lifestyle. Histologic examination of the specimens found inflammation of the bronchus in all 3 patients, but only two specimens had evidence of bronchiolar inflammation. In only 1 patient was there a reduction in bronchiole number. All 3 patients showed presence of emphysema. These cases are notable for the segmental distribution of the disease. Pathologic examination lends support to the theory that previous respiratory tract infection may play a role in the pathogenesis of this condition.

Cardiac torsion after lobectomy with partial pericardectomy.

Cardiac herniation and torsion after intrapericardial pneumonectomy without closure of the pericardium is widely recognized. However, such a complication occurring after lobectomy has been rarely discussed in the literature. We describe a case of cardiac torsion of late onset that developed in a woman who had undergone left upper lobectomy as part of a resection for a malignant thymoma.

Homograft as a conduit for superior vena cava syndrome.

This report outlines the management of a 30-year-old man with severe multiresistant mycobacterium tuberculosis of his right lung. Despite medical therapy he had open tuberculosis with positive sputum smears. A right pneumonectomy was undertaken, but due to distorted hilar anatomy, the superior vena cava was resected. Postoperatively, superior vena cava syndrome developed and failure of venous drainage was demonstrated by bilateral arum venography and computed tomographic scanning. The superior vena cava syndrome was successfully relieved using an aortic homograft as a superior vena cava replacement instead of a spiral vein graft or a prosthetic conduit.

Endoscopic vein harvesting with the aid of carbon dioxide insufflation.

Endoscopic harvesting of the long saphenous vein has been introduced to decrease the morbidity of obtaining venous conduit for coronary artery bypass grafting. Herein is described an endoscopic method using carbon dioxide insufflation into the tissues around the vein. This has several advantages; improved vision, no physical retraction required, easier development of tissue planes, and improved hemostasis.

Angiosarcoma of the heart causing cardiac rupture: a rare cause of hemopericardium.

Cardiac rupture as a complication of primary cardiac tumors has rarely been reported in the literature. The diagnosis is difficult to establish preoperatively, but echocardiography may provide the best assessment of cardiac damage. We found a loculated pericardial effusion on two-dimensional echocardiography, a finding that has been documented in two of the previous four case reports. A case of right atrial rupture is reported with review of other cases from the literature.

Thoracoscopic debridement of empyema thoracis.

BACKGROUND: The primary treatment of empyema thoracis remains intercostal tube drainage together with antibiotics. Failure of primary treatment has until recently been an indication for thoracotomy and decortication. Video-assisted thoracoscopic debridement (VATD) has increased the available treatment options but requires validation. METHODS: A retrospective analysis was undertaken of 44 consecutive patients who presented for surgical treatment of empyema thoracis over a 3-year period. RESULTS: Two patients were unsuitable for VATD and were treated with open decortication (OD). Thirty patients were successfully treated by VATD. Two patients were converted to OD at the first operation, and 10 patients required OD as a second procedure. The mean duration of preoperative symptoms before referral was 37.6 +/- 11.8 days (VATD) and 40.1 +/- 11.6 days (OD) (p = not significant). The mean duration of hospitalization before transfer was 13.7 +/- 2.4 days (VATD) and 11.5 +/- 3.4 days (OD) (p = not significant). Intercostal drainage was required for 4.0 +/- 0.3 days (VATD) and 8.5 +/- 2.0 days (OD) (p = 0.004). The postoperative hospital stay was 5.3 +/- 0.4 days (VATD) and 10.3 +/- 2.1 days (OD) (p = 0.001). CONCLUSIONS: Primary surgical therapy with VATD should be considered for all patients with pleural empyema, irrespective of the duration of symptoms. This approach does not preclude OD as a secondary procedure or conversion to OD after initial thoracoscopic assessment. The major advantages of VATD over OD are a shorter duration of postoperative intercostal drainage and reduced postoperative hospitalization.

Early and late outcome after diagnostic thoracoscopy and talc pleurodesis.

Although thoracoscopy is now recognized to be of both diagnostic and therapeutic value, the risks of this procedure have not been fully addressed. We retrospectively reviewed our experience with 100 patients who underwent 110 thoracoscopies during the period January 1989 to February 1991. Sixty-five men and 35 women (ratio of 1.9:1) underwent thoracoscopy using general anesthesia and intubation with a double-lumen endotracheal tube. The mean age was 64.2 +/- 11.6 years (range, 13 to 85 years). The diagnosis was established in 48 (85.7%) of the 56 patients with undiagnosed pleural effusions. Forty-four patients were referred for therapeutic thoracoscopic talc pleurodesis. Pleurodesis was successful in 42 patients (95.5%). Four patients (4%) had five postoperative complications (two bronchopleural fistulas, two chest infections, and one arrhythmia). Five patients (5%) died after thoracoscopy; mean age was 67.8 +/- 8.1 years (range, 55 to 77 years). The causes of death were cardiac arrest in 2, respiratory failure in 1, and malignant cachexia in 2. The findings of this study confirm that thoracoscopy can achieve high rates of diagnostic and therapeutic success but is not without attendant mortality in a high-risk patient population.

Effects of cardiopulmonary bypass on gut blood flow, oxygen utilization, and intramucosal pH.

Studies documenting rises in endotoxin after cardiopulmonary bypass (CPB) have postulated gut mucosal hypoperfusion. We have investigated alterations in jejunal blood flow by laser Doppler flow measurement, intramucosal pH (pHi) by tonometry, and oxygen utilization in a canine model of hypothermic CPB (n = 11 dogs). After 10 minutes of hypothermic CPB, despite no major reduction in superior mesenteric artery flow, mucosal laser Doppler flow decreased to -38.2% +/- 9.3% of levels obtained before bypass (p = 0.008) and serosal laser Doppler flow, to -47.3% +/- 11.4% (p = 0.006). During the hypothermic phase, mesenteric oxygen consumption fell from 0.18 +/- 0.01 to 0.098 +/- 0.01 mL.min-1.kg-1 (p = 0.005), and mesenteric oxygen delivery fell from 1.97 +/- 0.39 to 1.14 +/- 0.12 mL.min-1.kg-1 (p = 0.05). There was no change in jejunal pHi. During the rewarming phase, there was a substantial increase in mucosal laser Doppler flow, peaking at +69.8% +/- 15.2% (p = 0.03), whereas serosal laser Doppler flow returned to values seen prior to CPB (-16.4% +/- 21.5%; p = 0.25). These changes coincided with a surge in oxygen consumption (0.33 +/- 0.042 mL.min-1.kg-1; p = 0.009), while mesenteric oxygen delivery remained depressed at 1.09 +/- 0.12 mL.min-1.kg-1 (p = 0.04). Jejunal pHi fell from a value of 7.36 +/- 0.04 before CPB to 7.12 +/- 0.07 (p = 0.02), thus indicating mucosal hypoxia. During the rewarming phase of hypothermic CPB, there is a disparity between mesenteric oxygen consumption and oxygen delivery with villus tip ischemia; these findings may explain the pathophysiology of endotoxemia during CPB.

Left ventricular function and coronary artery disease progression early after coronary bypass grafting.

To investigate the effects of coronary artery disease progression on left ventricular function in patients who suffer angina early after coronary artery bypass grafting, we studied the progression of coronary stenoses, the occurrence of graft occlusions, and measured left ventricular ejection fraction (regional and global) in 34 consecutive patients who underwent repeat angiography 25.2 +/- 3.5 (standard error of the mean) months postoperatively, from a total population of 550 patients who underwent bypass grafting. Resting left ventricular function and stenosis severity were assessed using a computerized, quantitative analysis system. Coronary stenosis progression was defined as an increase in the percentage of the stenotic occlusion by 30% or more, any increase in lesion severity that resulted in total coronary artery occlusion, or the occurrence of a new stenosis that occluded the artery by 50% or more. Group 1 comprised 21 patients with all grafts patent and group 2 comprised 13 patients with one or more grafts occluded (20 of 34 grafts). Coronary artery disease progressed in all patients in group 1, and this involved 22 of 54 (41%) grafted vessels and 3 of 15 (20%) nongrafted vessels (p < 0.05). Coronary artery disease progressed in 11 patients in group 2, involving 15 of 32 (47%) grafted vessels and 1 of 6 (17%) nongrafted vessels (p < 0.01). An increased collateral circulation was observed in both groups. The left ventricular ejection fraction remained unchanged in both groups (group 1, 0.60 +/- 0.03 versus 0.62 +/- 0.03; group 2, 0.62 +/- 0.05 versus 0.62 +/- 0.04 before and after bypass, respectively; p = not significant) and there was no difference between the groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinoid heart disease: early failure of an allograft valve replacement.

A woman who had carcinoid syndrome and carcinoid heart disease underwent tricuspid and pulmonary valve replacements with a xenograft and a cryopreserved allograft, respectively. Within 3 months of the operation severe pulmonary regurgitation and pulmonary hypertension refractory to medical therapy developed. Autopsy found the biomechanical tricuspid valve to be free of disease but the allograft in the pulmonary position was involved by carcinoid heart disease in a fashion similar to the excised native pulmonary valve.

Magnetic resonance coronary artery imaging for redo coronary operations.

Imaging the native coronary vessels using contrast angiography can be difficult in the context of redo coronary operations when native disease is severe. When previous vein grafts undergo aneurysmal dilatation, imaging of the native vessel is restricted by the inability to infuse a sufficient volume of contrast medium through the graft and into the native vessel. We present a case of a patient whose redo coronary artery bypass graft operation was planned on the basis of magnetic resonance imaging of his native coronary arteries and vein graft after unsuccessful coronary angiography.