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Interhospital failure to rescue after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2023; 165:134-143.e3. [PMID: 33712236 PMCID: PMC8679510 DOI: 10.1016/j.jtcvs.2021.01.064] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 01/06/2021] [Accepted: 01/12/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE We evaluated whether interhospital variation in mortality rates for coronary artery bypass grafting was driven by complications and failure to rescue. METHODS An observational study was conducted among 83,747 patients undergoing isolated coronary artery bypass grafting between July 2011 and June 2017 across 90 hospitals. Failure to rescue was defined as operative mortality among patients developing complications. Complications included the Society of Thoracic Surgeons 5 major complications (stroke, surgical reexploration, deep sternal wound infection, renal failure, prolonged intubation) and a broader set of 19 overall complications. After creating terciles of hospital performance (based on observed:expected mortality), each tercile was compared on the basis of crude rates of (1) major and overall complications, (2) operative mortality, and (3) failure to rescue (among major and overall complications). The correlation between hospital observed and expected (to address confounding) failure to rescue rates was assessed. RESULTS Median Society of Thoracic Surgeons predicted mortality risk was similar across hospital observed:expected mortality terciles (P = .831). Mortality rates significantly increased across terciles (low tercile: 1.4%, high tercile: 2.8%). Although small in magnitude, rates of major (low tercile: 11.1%, high tercile: 12.2%) and overall (low tercile: 36.6%, high tercile: 35.3%) complications significantly differed across terciles. Nonetheless, failure to rescue rates increased substantially across terciles among patients with major (low tercile: 9.1%, high tercile: 14.3%) and overall (low tercile: 3.3%, high tercile: 6.8%) complications. Hospital observed and expected failure to rescue rates were positively correlated among patients with major (R2 = 0.14) and overall (R2 = 0.51) complications. CONCLUSIONS The reported interhospital variability in successful rescue after coronary artery bypass grafting supports the importance of identifying best practices at high-performing hospitals, including early recognition and management of complications.
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High-quality cardiac surgery through teamwork. Proc (Bayl Univ Med Cent) 2020; 34:215-220. [PMID: 33456201 DOI: 10.1080/08998280.2020.1811057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
The high-quality cardiothoracic surgery program is primed for mindful effective surgery. The challenge lies in attaining mindful skills and efficiency. Herein is one journey toward high departmental quality over two decades.
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Libman-Sacks Endocarditis Involving a Bioprosthesis in the Aortic Valve Position in Systemic Lupus Erythematosus. Am J Cardiol 2019; 124:316-318. [PMID: 31133276 DOI: 10.1016/j.amjcard.2019.04.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 11/16/2022]
Abstract
Described herein is a 39-year-old man with systemic lupus erythematosus not receiving corticosteroid therapy who developed Libman-Sacks endocarditis causing stenosis of a bioprosthesis in the aortic valve position.
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Major Adverse Renal and Cardiac Events After Coronary Angiography and Cardiac Surgery. Ann Thorac Surg 2018; 105:1724-1730. [DOI: 10.1016/j.athoracsur.2018.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/13/2017] [Accepted: 01/03/2018] [Indexed: 02/04/2023]
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Can use of an administrative database improve accuracy of hospital-reported readmission rates? J Thorac Cardiovasc Surg 2018; 155:2043-2047. [DOI: 10.1016/j.jtcvs.2017.11.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 10/05/2017] [Accepted: 11/19/2017] [Indexed: 10/18/2022]
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Efficacy and effectiveness of on- versus off-pump coronary artery bypass grafting: A meta-analysis of mortality and survival. J Thorac Cardiovasc Surg 2017; 155:172-179.e5. [PMID: 28958597 DOI: 10.1016/j.jtcvs.2017.08.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 07/24/2017] [Accepted: 08/09/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Despite many studies comparing on- versus off-pump coronary artery bypass graft (CABG), there is no consensus as to whether one of these techniques offers patients better outcomes. METHODS We searched PubMed from inception to June 30, 2015, and identified additional studies from bibliographies of meta-analyses and reviews. We identified 42 randomized controlled trials (RCTs) and 31 rigorously adjusted observational studies (controlling for the Society of Thoracic Surgeons-recognized risk factors for mortality) reporting mortality for off-pump versus on-pump CABG at specified time points. Trial data were extracted independently by 2 researchers using a standardized form. Differences in probability of mortality (DPM) were estimated for the RCTs and observational studies separately and combined, for time points ranging from 30 days to 10 years. RESULTS RCT-only data showed no significant differences at any time point, whereas observational-only data and the combined analysis showed short-term mortality favored off-pump CABG (n = 1.2 million patients; 36 RCTs, 26 observational studies; DPM [95% confidence interval (CI)], -44.8% [-45.4%, -43.8%]) but that at 5 years it was associated with significantly greater mortality (n = 60,405 patients; 3 RCTs, 5 observational studies; DPM [95% CI], 10.0% [5.0%, 15.0%]). At 10 years, only observational data were available, and off-pump CABG showed significantly greater mortality (DPM [95% CI], 14.0% [11.0%, 17.0%]). CONCLUSIONS Evidence from RCTs showed no differences between the techniques, whereas rigorously adjusted observational studies (with >1.1 million patients) and the combined analysis indicated that off-pump CABG offers lower short-term mortality but poorer long-term survival. These results suggest that, in real-world settings, greater operative safety with off-pump CABG comes at the expense of lasting survival gains.
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Impact of Accurate 30-Day Status on Operative Mortality: Wanted Dead or Alive, Not Unknown. Ann Thorac Surg 2017; 104:1987-1993. [PMID: 28859926 DOI: 10.1016/j.athoracsur.2017.05.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 04/26/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Risk-adjusted operative mortality is the most important quality metric in cardiac surgery for determining The Society of Thoracic Surgeons (STS) Composite Score for star ratings. Accurate 30-day status is required to determine STS operative mortality. The goal of this study was to determine the effect of unknown or missing 30-day status on risk-adjusted operative mortality in a regional STS Adult Cardiac Surgery Database cooperative and demonstrate the ability to correct these deficiencies by matching with an administrative database. METHODS STS Adult Cardiac Surgery Database data were submitted by 27 hospitals from five hospital systems to the Texas Quality Initiative (TQI), a regional quality collaborative. TQI data were matched with a regional hospital claims database to resolve unknown 30-day status. The risk-adjusted operative mortality observed-to-expected (O/E) ratio was determined before and after matching to determine the effect of unknown status on the operative mortality O/E. RESULTS TQI found an excessive (22%) unknown 30-day status for STS isolated coronary artery bypass grafting cases. Matching the TQI data to the administrative claims database reduced the unknowns to 7%. The STS process of imputing unknown 30-day status as alive underestimates the true operative mortality O/E (1.27 before vs 1.30 after match), while excluding unknowns overestimates the operative mortality O/E (1.57 before vs 1.37 after match) for isolated coronary artery bypass grafting. CONCLUSIONS The current STS algorithm of imputing unknown 30-day status as alive and a strategy of excluding cases with unknown 30-day status both result in erroneous calculation of operative mortality and operative mortality O/E. However, external validation by matching with an administrative database can improve the accuracy of clinical databases such as the STS Adult Cardiac Surgery Database.
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Abstract
Described herein is a 67-year-old morbidly obese man who had a lipoma excised from his posterior mitral leaflet after it was found by echocardiogram. Findings in 6 other previously reported cases are reviewed.
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Comparison of Outcomes of Operative Therapy for Acute Type A Aortic Dissections Provided at High-Volume Versus Low-Volume Medical Centers in North Texas. Am J Cardiol 2017; 119:323-327. [PMID: 27839772 DOI: 10.1016/j.amjcard.2016.09.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 09/29/2016] [Accepted: 09/29/2016] [Indexed: 12/12/2022]
Abstract
Immediate surgery is standard therapy for acute type A aortic dissections (TAAD). Because of its low incidence, many smaller cardiac surgery programs do not routinely perform this procedure because it may negatively affect outcomes. Many high-risk, low-volume (LV) surgical procedures are now preferentially performed in reference centers. We compared the outcomes of surgery for TAAD in high-volume (HV) and LV centers in a single metropolitan area to determine the optimal setting for treatment. Thirty-five of the 37 cardiac surgery programs in the Dallas Ft. Worth metropolitan area participate in a regional consortium to measure outcomes collected in the Society of Thoracic Surgeons Adult Cardiac Database. From January 01, 2008, to December 31, 2014, 29 programs had treated TAAD. Those programs performing at least 100 operations for TAAD were considered HV centers and the others LV. Surgery for TAAD was performed in 672 patients over the 7-year study period with HV centers performing 469 of 672 (70%) of the operations. Despite similar preoperative characteristics, operative mortality was significantly lower in HV versus LV centers (14.1% vs 24.1%; p = 0.001). There was no significant difference in postoperative paralysis rates (2.6% vs 4.5%; p = 0.196), stroke rates (10.7% vs 9.4%; p = 0.623), or 30-day readmission rates (12.1% vs 15.5%; p = 0.292). An improved survival rate in HV centers was maintained over a 5-year follow-up period. Surgery for TAAD in a single large metropolitan area was most commonly performed in HV centers. In conclusion, the treatment of acute thoracic aortic dissection is recommended to be performed in reference centers because of lower early and midterm mortality.
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Leukocyte filtration and miniature perfusion during arrested heart CABG on a Jehovah’s Witness patient. Perfusion 2016; 19:375-9. [PMID: 15619972 DOI: 10.1191/0267659104pf773cr] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Bloodless surgery and a reduction in the use of allogeneic blood products has long been the standard of care in medicine. Many individuals in our communities have demanded this form of surgical treatment for personal and religious reasons. On 6 December 2002, a 72-year-old male patient was admitted to our institution as a critical air flight transfer. The patient’s height was 190.5 cm and weight was 59.3 kg (body surface area 1.83 m2). His preliminary diagnosis was chest pain with myocardial infarction as evidenced by elevated blood cardiac isoenzymes. His principle diagnosis was subendocardial infarction with paroxysmal ventricular tachycardia. Cardiac catheterization was performed and demonstrated severe triple vessel disease with an ejection fraction of 30%. He was evaluated and accepted as a candidate for coronary artery bypass grafting. Multidisciplinary consultation concluded that a safe and effective method of perioperative treatment would involve the use of arrested heart support with cold blood cardioplegia using a low prime miniature perfusion circuit as no blood products would be considered for use. Additionally, the combined modalities of perfusion interventions to minimize hemodilution consisted of intraoperative autologous blood collection totaling 500 mL and rapid autologous priming of the miniature perfusion circuit. The miniature perfusion system was a low prime Cardiovention (Santa Clara, CA) CORx device which includes a hollow-fiber oxygenator and integral centrifugal pump with a surface area of 1.2 m2. This system also incorporates an air sensing solenoid which triggers rapid air evacuation in a bolus range of 1 mL or greater. Kinetic venous drainage is another feature of this device as the centrifugal pump is integrated into the oxygenator. We believed that a miniature extracorporeal circuit would enhance the desired clinical outcome as opposed to the risk of: (1) off-pump coronary artery bypass (OPCAB) approach and the concern of emergent transition to an on-pump procedure and (2) use of larger surface area with conventional systems that impose a greater hemodilutional effect. Leukocyte filtration was employed as the patient had a significant past medical history of chronic obstructive pulmonary disease. We herein report our clinical experience with this method of treatment on a patient who refused the use of blood products in his surgical treatment. It is our belief that the multiple modalities utilized in combination during this procedure resulted in positive clinical outcomes as demonstrated by an intubation time of 8 hours 35 min with a discharge on the fifth postoperative day.
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Mitral Valve Replacement After Failed Mitral Ring Insertion With or Without Leaflet/Chordal Repair for Pure Mitral Regurgitation. Am J Cardiol 2016; 117:1790-807. [PMID: 27087174 DOI: 10.1016/j.amjcard.2016.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 10/22/2022]
Abstract
Mitral repair operations for correction of pure mitral regurgitation (MR) are generally quite successful. Occasionally, however, the reparative procedure incompletely corrects the MR or the MR recurs. From March 1993 to January 2016, twenty nine patients had mitral valve replacement after the initial mitral repair operation, and observations in them were analyzed. All 29 patients at the repair operation had an annular ring inserted and later (<1 year in 6 and >1 year in 21) mitral valve replacement. The cause of the MR before the repair operation appears to have been prolapse in 16 patients (55%), secondary (functional) in 12 (41%) (ischemic in 5), and infective endocarditis which healed in 1 (3%). At the replacement operation the excised anterior mitral leaflet was thickened in all 29 patients. Some degree of stenosis appeared to have been present in 16 of the 29 patients before the replacement operation, although only 10 had an echocardiographic or hemodynamic recording of a transvalvular gradient; at least 11 patients had restricted motion of the posterior mitral leaflet; 10, ring dehiscence; 2, severe hemolysis; and 2, left ventricular outflow obstruction. In conclusion, there are multiple reasons for valve replacement after earlier mitral repair. Uniformly, at the time of the replacement, the mitral leaflets were thickened by fibrous tissue. Measurement of the area enclosed by the 360° rings and study of the excised leaflet suggest that the ring itself may have contributed to the leaflet scarring and development of some transmitral stenosis.
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Excess short-term mortality in women after isolated coronary artery bypass graft surgery. Open Heart 2016; 3:e000386. [PMID: 27042323 PMCID: PMC4809184 DOI: 10.1136/openhrt-2015-000386] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/21/2016] [Accepted: 02/14/2016] [Indexed: 01/28/2023] Open
Abstract
Objective Female sex is considered a risk factor for adverse outcomes following isolated coronary artery bypass graft (CABG) surgery. We assessed the association between sex and short-term mortality following isolated CABG, and estimated the ‘excess’ deaths occurring in women. Methods Short-term mortality was investigated in 13 327 consecutive isolated CABG patients in North Texas between January 2008 and December 2012. The association between sex and CABG short-term mortality, and the excess deaths among women were assessed via a propensity-adjusted (by Society of Thoracic Surgeons-recognised risk factors) generalised estimating equations model approach. Results Short-term mortality was significantly higher in women than men (adjusted OR=1.39; 95% CI 1.04 to 1.86; p=0.027). This significantly greater risk translates into 35 ‘excess’ deaths among women included in this study (>10% of the total 343 deaths in the study cohort) and into 392 ‘excess’ deaths among the ∼40 000 women undergoing isolated CABG in the USA each year. Conclusions The higher risk associated with female sex lead to 35 ‘excess’ deaths in women in this study cohort (over 10% of the total deaths) and to 392 ‘excess’ deaths among women undergoing isolated CABG in the USA each year. Further research is needed to assess the causal mechanisms underlying this sex-related difference. Results of such work could inform the development and implementation of sex-specific treatment and management strategies to reduce women's mortality following CABG. Based on our results, if such work brought women's short-term mortality into line with men's, total short-term mortality could be reduced by up to 10%.
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An alternative approach to prescribing sternal precautions after median sternotomy, "Keep Your Move in the Tube". Proc (Bayl Univ Med Cent) 2016; 29:97-100. [PMID: 26722187 DOI: 10.1080/08998280.2016.11929379] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Traditional sternal precautions, given to sternotomy patients as part of their discharge education, are intended to help prevent sternal wound complications. They vary widely but generally include arbitrary load and time restrictions (lifting no more than a specified weight for up to 12 weeks) and may prohibit common shoulder joint and shoulder girdle movements. Having observed the negative effects of restrictive sternal precautions for many years, our research team performed a series of studies that measured the forces exerted during various common activities and their relationship to the sternum. The results, though informative, led us to realize that the goal of identifying "the" appropriate load restriction to prescribe for sternotomy patients was futile. The alternative approach that we introduce applies standard kinesiological principles and teaches patients how to perform load-bearing movements in a way that avoids excessive stress to the sternum.
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Inferior vena cava reconstruction for leiomyosarcoma of Zone I-III requiring complete hepatectomy and bilateral nephrectomy with autotransplantation. J Surg Oncol 2015; 112:481-5. [PMID: 26356493 DOI: 10.1002/jso.24041] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 08/26/2015] [Indexed: 11/06/2022]
Abstract
The inferior vena cava (IVC) is the most common site of leiomyosarcomas arising from a vascular origin. Leiomyosarcomas of the IVC are categorized by anatomical location. Zone I refers to the infrarenal portion of the IVC, Zone II from the hepatic veins to the renal veins, and Zone III from the right atrium to the hepatic veins. This is a rare presentation of a Zone I-III leiomyosarcoma. Fifty-two-years-old female with a medical history significant only for HTN was admitted to the hospital with bilateral lower extremity edema and dyspnea. Two-dimensional echo demonstrated a right atrial thrombus, extending into the IVC. On subsequent CT and MRI, a 15 cm mass was noted that began in the right atrium and extended into the IVC, with continuation below the renal veins to above the level of the confluence of the common iliac veins. The patient underwent a complete resection of the mass, replacement of the IVC with Dacron graft, total hepatectomy and bilateral nephrectomy, with liver and kidney autotransplantation. Pathology was consistent with a high grade spindle cell sarcoma of vena cava origin. Patient was readmitted approximately 4 weeks postoperatively to begin adjuvant chemotherapy. This case represents a zone I-III IVC leiomyosarcoma treated with surgical R0 resection. This included a hepatectomy, bilateral nephrectomy, and hepatic and left renal autotransplantation. These complex tumors should be treated with surgical resection, and require a multidisciplinary approach.
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Effect of gender and race on operative mortality after isolated coronary artery bypass grafting. Am J Cardiol 2015; 115:614-8. [PMID: 25596952 DOI: 10.1016/j.amjcard.2014.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 12/11/2014] [Accepted: 12/11/2014] [Indexed: 11/18/2022]
Abstract
Studies examining outcomes after coronary artery bypass grafting (CABG) by gender and/or race have shown conflicting results. It remains to be determined if, or how, gender and race are independent risk factors for CABG operative mortality. Using all consecutive patients who underwent isolated CABG at Baylor University Medical Center in Dallas, Texas, from January 2004 to October 2011, the risk-adjusted associations between gender and race, respectively, and operative mortality were estimated using a generalized propensity approach, accounting for recognized Society of Thoracic Surgeons risk factors for mortality. Women were nearly 2 times more likely to die during or within 30 days of the operation than men (odds ratio 1.96, 95% confidence interval 1.44 to 2.66, p <0.0001), while no significant mortality differences were observed among races. In conclusion, these findings suggest that women face a significantly greater risk for operative death that should be taken into account during the treatment decision-making process but that race is not associated with CABG mortality and so should not be among the factors considered.
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Clues to diagnosing carcinoid heart disease as the cause of isolated right-sided heart failure. Am J Cardiol 2014; 114:1623-6. [PMID: 25260947 DOI: 10.1016/j.amjcard.2014.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 08/15/2014] [Accepted: 08/15/2014] [Indexed: 11/27/2022]
Abstract
Described herein is a 67-year-old woman who underwent replacement of both tricuspid and pulmonic valves because of severe isolated right-sided systolic heart failure. The cause of the heart failure preoperatively was believed to be the result of left breast radiation a year earlier. At operation, however, the pulmonic valve was excised and a biopsy of the stiff-walled right atrium was performed, and histologic examination of each was classic of carcinoid heart disease. She never awoke postoperatively. Postoperatively, computed tomography disclosed numerous masses in the liver. Retrospectively, clues to the presence of carcinoid heart disease include thickening of both the tricuspid and pulmonic valve leaflets by echocardiogram, a pressure gradient, albeit small, across the pulmonic valve, the plastering of the septal tricuspid-valve leaflet to the ventricular septum, the total absence of left-sided heart disease, and the presence of extremely low 12-lead QRS electrocardiographic voltage.
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Quality-of-life outcomes with coronary artery bypass graft surgery in ischemic left ventricular dysfunction: a randomized trial. Ann Intern Med 2014; 161:392-9. [PMID: 25222386 PMCID: PMC4182862 DOI: 10.7326/m13-1380] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The STICH (Surgical Treatment for Ischemic Heart Failure) trial compared a strategy of routine coronary artery bypass grafting (CABG) with guideline-based medical therapy for patients with ischemic left ventricular dysfunction. OBJECTIVE To describe treatment-related quality-of-life (QOL) outcomes, a major prespecified secondary end point in the STICH trial. DESIGN Randomized trial. (ClinicalTrials.gov: NCT00023595). SETTING 99 clinical sites in 22 countries. PATIENTS 1212 patients with a left ventricular ejection fraction of 0.35 or less and coronary artery disease. INTERVENTION Random assignment to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). MEASUREMENTS A battery of QOL instruments at baseline (98.9% complete) and 4, 12, 24, and 36 months after randomization (collection rates were 80% to 89% of those eligible). The principal prespecified QOL measure was the Kansas City Cardiomyopathy Questionnaire, which assesses the effect of heart failure on patients' symptoms, physical function, social limitations, and QOL. RESULTS The Kansas City Cardiomyopathy Questionnaire overall summary score was consistently higher (more favorable) in the CABG group than in the medical therapy group by 4.4 points (95% CI, 1.8 to 7.0 points) at 4 months, 5.8 points (CI, 3.1 to 8.6 points) at 12 months, 4.1 points (CI, 1.2 to 7.1 points) at 24 months, and 3.2 points (CI, 0.2 to 6.3 points) at 36 months. Sensitivity analyses to account for the effect of mortality on follow-up QOL measurement were consistent with the primary findings. LIMITATION Therapy was not masked. CONCLUSION In this cohort of symptomatic high-risk patients with ischemic left ventricular dysfunction and multivessel coronary artery disease, CABG plus medical therapy produced clinically important improvements in quality of life compared with medical therapy alone over 36 months. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Relation between topical application of platelet-rich plasma and vancomycin and severe deep sternal wound infections after a first median sternotomy. Am J Cardiol 2014; 113:1415-9. [PMID: 24576548 DOI: 10.1016/j.amjcard.2013.12.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 12/30/2013] [Accepted: 12/30/2013] [Indexed: 10/25/2022]
Abstract
Deep sternal wound infections (DSWIs) are serious complications of sternotomy, leading to increased mortality and costs of care. Topical applications of autologous platelet concentrate and vancomycin have both shown promise in preventing DSWIs. From January 1, 1998, to November 30, 2010, 1,866 patients without previous sternotomy underwent cardiac surgery at the Baylor University Medical Center, Dallas, by a single surgeon who systematically adopted application of a paste containing vancomycin, calcium-thrombin, and platelet-rich plasma (PRP paste) to the edges of sternal wounds before closure in December 2005. A propensity-adjusted logistic regression model employing Firth's penalized maximum likelihood method was used to assess the association between the use of the PRP paste (intervention) and the incidence of severe DSWI. Eleven patients (0.59%) developed severe DSWIs. All were among the 1,318 patients in the control group (0.83%); no severe DSWIs developed in the 548 patients in the intervention group. Both the unadjusted and adjusted associations between the study intervention and DSWI were statistically significant (unadjusted p value=0.021; adjusted p value=0.005; adjusted odds ratio=0.05, 95% confidence interval 0.01, 0.50). In conclusion, the PRP paste appears to prevent severe DSWIs.
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Dexmedetomidine infusion for analgesia up to 48 hours after lung surgery performed by lateral thoracotomy. Proc (Bayl Univ Med Cent) 2014; 27:3-10. [PMID: 24381392 DOI: 10.1080/08998280.2014.11929035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Patients undergoing a lateral thoracotomy for pulmonary resection have moderate to severe pain postoperatively that is often treated with opioids. Opioid side effects such as respiratory depression can be devastating in patients with already compromised respiratory function. This prospective double-blinded clinical trial examined the analgesic effects and safety of a dexmedetomidine infusion for postthoracotomy patients when administered on a telemetry nursing floor, 24 to 48 hours after surgery, to determine if the drug's known early opioid-sparing properties were maintained. Thirty-eight thoracotomy patients were administered dexmedetomidine intraoperatively and overnight postoperatively and then randomized to receive placebo or dexmedetomidine titrated from 0.1 to 0.5 μg·kg·h(-1) the day following surgery for up to 24 hours on a telemetry floor. Opioids via a patient-controlled analgesia pump were available for both groups, and vital signs including transcutaneous carbon dioxide, pulse oximetry, respiratory rate, and pain and sedation scores were monitored. The dexmedetomidine group used 41% less opioids but achieved pain scores equal to those of the placebo group. The mean heart rate and systolic blood pressure were lower in the dexmedetomidine group but sedation scores were better. The mean respiratory rate and oxygen saturation were similar in the two groups. Mild hypercarbia occurred in both groups, but periods of significant respiratory depression were noted only in the placebo group. Significant hypotension was noted in one patient in the dexmedetomidine group in conjunction with concomitant administration of a beta-blocker agent. The placebo group reported a higher number of opioid-related adverse events. In conclusion, the known opioid-sparing properties of dexmedetomidine in the immediate postoperative period are maintained over 48 hours.
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Abnormal origin of the left internal thoracic artery detected only by computed tomography. Proc (Bayl Univ Med Cent) 2013; 26:283-4. [PMID: 23814392 DOI: 10.1080/08998280.2013.11928984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
The origins of the branches of the subclavian artery are known to be variable. We present the case of a 55-year-old man whose coronary artery bypass surgery necessitated the use of the internal thoracic artery as he lacked other suitable venous conduits. The left internal thoracic artery appeared to be absent on subselective subclavian angiography. Computed tomographic angiography revealed a previously undescribed anomaly: origin of the internal thoracic artery from a thyrocervical trunk arising directly from the aortic arch.
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Abstract
Twenty-eight patients from a single surgeon and center underwent atrial fibrillation surgery using a diode-pumped laser. A left-sided modified (pulmonary vein encircling with connecting lesions) or a complete modified Cox-Maze III operation was employed. Of the 28 patients, 23 were available for retrospective evaluation and Holter monitoring, and 21 patients elected to participate in a follow-up study. The Society for Thoracic Surgeons database was used for in-hospital experience. All 21 patients were studied >6 months after surgery and received a 24-hour Holter monitor and an SF-36v2 quality of life survey. The mean follow-up time was 18.1 months. Among this group, one patient was in atrial fibrillation and four experienced atrial tachyarrhythmias at the time of Holter monitoring. Five patients (24%) underwent cardioversion after operation, and nine patients (43%) were on warfarin. No patients were treated with repeat ablation. One patient required a pacemaker postoperatively. We observed 95% freedom from atrial fibrillation and 76% freedom from all atrial tachyarrhythmias in the study group. No complications or deaths were device related. In conclusion, the use of a diode-pumped laser appears to be safe and effective for the treatment of atrial fibrillation.
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A tribute to John Capehart, MD, "Sooner proud" and 1961 National Spelling Bee champion. Proc AMIA Symp 2011; 24:343-5. [PMID: 22046071 DOI: 10.1080/08998280.2011.11928753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Safety and Efficacy of Ixmyelocel-T, an Expanded Patient-Specific Mixed Cell Product, in Dilated Cardiomyopathy (IMPACT-DCM). J Card Fail 2011. [DOI: 10.1016/j.cardfail.2011.06.196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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25
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Diagnosis of congenital unicuspid aortic valve by 64-slice cardiac computed tomography. Proc (Bayl Univ Med Cent) 2011; 21:139. [PMID: 18382752 DOI: 10.1080/08998280.2008.11928379] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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26
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Initial experience in the treatment of thoracic aortic aneurysmal disease with a thoracic aortic endograft at Baylor University Medical Center. Proc (Bayl Univ Med Cent) 2011; 21:115-9. [PMID: 18382748 DOI: 10.1080/08998280.2008.11928373] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
A retrospective review of 27 patients who underwent endovascular repair of thoracic aneurysms and of other thoracic aortic pathology with the thoracic aortic endograft (Gore Medical, Flagstaff, AZ) from June 2005 to July 2007 was performed. The mean follow-up period was 13.5 months (range, 2-25 months). Indications for thoracic endografting included descending thoracic aneurysms (n = 18), thoracoabdominal aneurysms (n = 3), traumatic aortic injuries (n = 3), penetrating aortic ulcers (n = 2), and contained rupture of a type B dissection (n = 1). One patient died during the procedure, for an overall mortality rate of 3.7%. The average length of stay was 8.1 days, with an average stay in the intensive care unit of 4.2 days. If patients with traumatic aortic injuries were excluded, the average overall and intensive care unit length of stay were 5.6 and 1.8 days, respectively. There was one incident of spinal cord ischemia (3.7%). There were five type I or type III endoleaks, three of which required revision (11.1%). In conclusion, thoracic endografting is a safe and viable option for the repair of descending thoracic aneurysms and other aortic pathologies. We have found it to be less invasive, even in conjunction with preoperative debranching procedures, with a shorter recovery time, decreased perioperative morbidity and blood loss, and decreased peri-operative mortality compared with standard open repair.
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Embolization of a stent from an arteriovenous graft into the right ventricle in a patient on chronic hemodialysis. Proc AMIA Symp 2011; 24:94-5. [PMID: 21566752 DOI: 10.1080/08998280.2011.11928691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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28
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Abstract
BACKGROUND Clampless proximal anastomoses are associated with fewer strokes in coronary artery bypass (CAB) graft surgery, but lack of patency of proximal grafts has been an issue. The Spyder (Medtronic, Minneapolis, MN, USA) is an "exoconnector" device that deploys a nitinol clamping mechanism to attach a vein onto the aortotomy and create the proximal anastomosis. METHODS During a 22-month period we performed gated cardiac computed tomographic angiography on 38 patients who underwent off-pump CAB. RESULTS Of the 49 proximal anastomoses created with the Spyder, 44 (90%) remained patent at the time of study, with a mean follow-up period of 16.7 months. CONCLUSIONS The use of the Spyder exoconnector to create a clampless proximal anastomosis during off-pump CAB surgery is a reasonable strategy to improve graft patency.
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Mass in the neck after radiation exposure from Chernobyl disaster. Proc AMIA Symp 2009; 22:156-61. [PMID: 19381320 DOI: 10.1080/08998280.2009.11928503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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30
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Preoperative Visualization of a Muscular Ventricular Septal Defect by 64-Slice Cardiac Computed Tomography. Proc (Bayl Univ Med Cent) 2008; 21:281. [DOI: 10.1080/08998280.2008.11928411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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31
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Measurement of right ventricular volumes before and after atrial septal defect closure using multislice computed tomography. Am J Cardiol 2007; 99:1458-61. [PMID: 17493480 DOI: 10.1016/j.amjcard.2006.12.075] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2006] [Revised: 12/21/2006] [Accepted: 12/21/2006] [Indexed: 11/24/2022]
Abstract
Volumetric measurements of the right ventricle are helpful in patients with atrial septal defects (ASDs) in estimating the degree of right ventricular (RV) failure. They also may be important in following patients postoperatively after ASD closure. Traditional imaging modalities used to obtain such measurements have had limitations in measuring the complex shape of the right ventricle. Multislice computed tomography (MSCT) is a technique that provides excellent spatial resolution of the moving heart. This study was conducted to assess whether MSCT could be used to evaluate RV end-diastolic volume (EDV) before and after the closure of an ASD. From June 2004 to March 2006, 10 patients with ASDs underwent MSCT to calculate their RV volumes. The patients then had their ASDs closed by either a percutaneous or a surgical approach. Three months later, the patients' MSCT scans were repeated, and RV volumes were recalculated. EDV was approximated using 3-dimensional volume-rendered models of the right ventricle. At a mean follow-up of 3 months, a significant reduction in mean RV EDV, indexed for body surface area, was demonstrated, from 131 +/- 31 to 83 +/- 22 cm(3)/m(2) (p = 0.0007). In conclusion, this report is the first to describe the utility of MSCT to demonstrate RV EDV reduction after ASD closure.
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Initial Experience in the Treatment of Thoracic Aortic Aneurysmal Disease with a Thoracic Aortic Endograft at Baylor University Medical Center. Proc (Bayl Univ Med Cent) 2007. [DOI: 10.1080/08998280.2007.11928255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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33
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64-Slice CT Angiography of Saphenous Vein Graft Anastomoses Fashioned With Interrupted Nitinol Clips. Ann Thorac Surg 2007; 83:1204. [PMID: 17307500 DOI: 10.1016/j.athoracsur.2006.02.084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2006] [Revised: 02/16/2006] [Accepted: 02/27/2006] [Indexed: 10/23/2022]
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Effect of body mass index on risk of long-term mortality following coronary artery bypass grafting. Am J Cardiol 2006; 98:734-8. [PMID: 16950173 DOI: 10.1016/j.amjcard.2006.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2006] [Revised: 04/14/2006] [Accepted: 04/14/2006] [Indexed: 11/21/2022]
Abstract
The effect of obesity on long-term mortality after coronary artery bypass grafting (CABG) remains inconclusive, partly due to methodologic issues in previous studies. We examined the effect of obesity on long-term mortality (up to a 6-year follow-up) in adult patients with a body mass index (BMI) > or =18.5 kg/m2 who underwent CABG at Baylor University Medical Center (Dallas, Texas) between January 1998 and August 1999 (n = 1,209). Unadjusted analysis indicated a strong association between BMI and long-term mortality (p = 0.001), with a decreased risk of mortality associated with increasing BMI. After adjusting for factors shown to be confounders of this relation (age, diabetes mellitus, chronic obstructive lung disease, renal failure, ejection fraction, and left main disease), the estimated association was no longer significant (p = 0.425). In conclusion, the apparent survival benefit associated with higher BMI became nonsignificant when the relation between mortality and BMI was adjusted, first for age and then for diabetes mellitus, chronic obstructive lung disease, renal failure, ejection fraction, and left main disease. This relation was masked in the crude analysis primarily by the effect of age. Patients with a high BMI were typically younger than patients with a lower BMI, suggesting that physicians and surgeons may only recommend/perform CABG for patients with a high BMI with an otherwise lower risk profile.
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Transmyocardial laser revascularization causes sustained VEGF secretion. Semin Thorac Cardiovasc Surg 2006; 18:43-5. [PMID: 16766253 DOI: 10.1053/j.semtcvs.2006.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2006] [Indexed: 11/11/2022]
Abstract
Transmyocardial laser revascularization (TMR) using a carbon dioxide (CO(2)) laser has been shown to relieve angina, increase vascular density, and improve myocardial contraction. A study of 28 patients receiving TMR was conducted to monitor vascular endothelial growth factor (VEGF) levels with the goal of clarifying the relationship between TMR, the amelioration of angina, and vascular density. Serum VEGF levels were measured during four periods (preoperative, postoperative, convalescence, and late) in these 28 patients who received sole therapy TMR for un-revascularizable ischemic angina and the levels were compared with the control group consisting of 10 nonischemic thoracotomy patients. Twelve of the 28 patients had previous coronary artery bypass graft(s); 10 had unstable angina, and 1 had an ejection fraction less than 30%. Overall, angina class was reduced from 3.8 +/- 0.9 to 1.0 +/- 0.9 (P < 0.01) at the 1-year follow-up. There were no perioperative mortalities; however, there was one late mortality. The results show that VEGF levels were higher in the convalescence and late periods. Specifically in the late period, VEGF levels in TMR therapy patients surpassed those of the control group and normalized VEGF levels were three times higher in the late period than preoperatively. The sustained VEGF secretion observed in this study may help to explain why CO(2) TMR therapy causes locally increased vascular density and angina relief.
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Angiographic confirmation of graft patency after coronary artery bypass graft surgery using interrupted nitinol clips. Proc (Bayl Univ Med Cent) 2006; 16:399-400. [PMID: 16278756 PMCID: PMC1214559 DOI: 10.1080/08998280.2003.11927936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Transmural Atrial Lesions with Laser and Optical Fiber Delivery: The Atrilaze. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2006. [DOI: 10.1097/01243895-200600140-00089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Clampless Anastomosis: Novel Device for Clampless Proximal Vein Anastomosis in OPCAB Surgery--The Initial Spyder Experience. Heart Surg Forum 2005; 8:E443-6. [PMID: 16283982 DOI: 10.1532/hsf98.20041161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The Spyder is a novel device that enables the attachment of a vein to the aorta by compliant, interrupted anastomosis; this minimizes aortic manipulation during off pump-coronary artery bypass (OPCAB) surgery. Its use may reduce transcranial Doppler signals recorded during CABG. We performed 250 anastomoses in 160 OPCAB cases in many centers and recorded efficiency and efficacy data. There were no adverse events noted during the operative period. In a subset of patients in one center, flow (n = 48) and transcranial Doppler signals (n = 22) were measured. We found the device to be a useful adjunct for minimally invasive CABG surgery.
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Abstract
The Coalescent IPAD (Coalescent Surgical, Sunnyvale, CA, USA) is a novel device that enables creation of a compliant proximal vein anastomosis to the aorta during off-pump coronary artery bypass (OPCAB) surgery while reducing the risk of cerebrovascular emboli and early stenosis. We performed IPAD-created anastomoses in 76 patients having standard OPCAB surgery. Following the procedures, no patients developed myocardial infarctions or reported angina, suggesting patency of the vein grafts to be of high quality. We found the device to be a useful adjunct for minimally invasive CAB graft surgery.
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Transesophageal echocardiographic visualization of a rupturing thoracic aortic aneurysm in progress. Echocardiography 2005; 22:277-8. [PMID: 15725166 DOI: 10.1111/j.0742-2822.2005.04048.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Perfusion-assisted beating heart support with a miniature extracorporeal circuit and leukocyte filtration: a 58-year-old patient with severe COPD. Perfusion 2004; 19:369-73. [PMID: 15619971 DOI: 10.1191/0267659104pf772cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patients with severe chronic obstructive pulmonary disease (COPD) impose a significant risk for postoperative morbidity and mortality requiring cardiovascular surgical intervention and the use of extracorporeal circulation. Recently, we treated a 58-year-old male with acute coronary syndrome complicated with recurrent ventricular arrhythmia, hypoxemia secondary to severe COPD and resolving pneumonia, who required urgent coronary revascularization. A novel operative strategy was used that included beating heart bypass grafting with cardiac decompression and support with a miniature perfusion circuit, kinetic-assisted venous return, rapid autologous priming and leukocyte filtration. The combination of multiple modalities was chosen because the patient was in a pre-existing inflammatory condition and had severe COPD. We herein report our perioperative clinical experience with this patient and the use of multiple modalities for extracorporeal perfusion therapy in managing this challenging case. We believe that, based upon his clinical course of ventilation time (17.4 hours) and postoperative length of hospital stay (5 days), this high risk patient demonstrated a positive clinical outcome as a result of these techniques.
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Abstract
The distal coronary artery bypass graft anastomosis created by an interrupted technique using nitinol clips is likely superior to that created with continuous suture because surgeons place clips with optimal visualization, and the anastomosis exhibits optimal compliance and cannot become a "purse-string" once constructed. Skillful use of the clips allows the surgeon to work in the ever more cramped quarters of the minithoracotomy or minimally invasive incision. Anastomosing vessels without knot tying is a valuable practice in the application of remote and robotic surgeries.
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Abstract
BACKGROUND Atrial fibrillation is the most common complication after cardiac surgery. Current medical treatment using antiarrhythmics and anticoagulants has a significant morbidity. The goal of this study was to determine if epicardial atrial defibrillation can be safely performed and return patients to sinus rhythm. METHODS A prospective analysis of patients undergoing cardiac surgery was performed. Patients with a prior pacemaker/defibrillator, history of arrhythmia, preoperative antiarrhythmic, age greater than 85 years, history of stroke, or intraaortic balloon pump were excluded. Temporary epicardial atrial cardioversion wires were placed on the right and left atrium. Bipolar atrial and ventricular pacing wires were also placed. The wires were tested in the operating room. Patients who went into postoperative arial fibrillation were cardioverted with 3 J, 6 J, or 9 J. RESULTS There were 45 patients enrolled. Sixteen patients (35%) went into postoperative arial fibrillation during their hospital stay. Mean time to onset of arial fibrillation was 2.6 +/- 1.4 days after surgery. Fifteen patients were successfully cardioverted to sinus rhythm on the primary cardioversion, with mean of 5.7 +/- 2.4 J. One patient was cardioverted at 6 hours after onset of arial fibrillation, at 6 J. Recurrent arial fibrillation occurred in 4 patients during their hospital stay. All 4 of these patients were cardioverted with a mean of 6.4 +/- 2.6 J. All wires were removed the day before patients were discharged. There were no complications with wire insertion or removal. There were no adverse neurologic events. The mean hospital stay was 5.1 +/- 2.2 days. All patients were in sinus rhythm at 1 month follow-up. CONCLUSIONS The use of a temporary atrial defibrillator to resynchronize patients in postoperative arial fibrillation is safe and effective.
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Severe late (16 years) dysfunction of a bioprosthesis in the mitral valve position without dysfunction of a bioprosthesis in the aortic valve position. Proc (Bayl Univ Med Cent) 2004; 17:214. [PMID: 16200102 PMCID: PMC1200654 DOI: 10.1080/08998280.2004.11927971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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46
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Abstract
BACKGROUND The accumulation of activated leukocytes in the pulmonary circulation plays an important role in the pathogenesis of lung dysfunction associated with cardiopulmonary bypass (CPB). Patients undergoing valve surgery have prolonged CPB owing to the complexity of the surgery. The goal of this study is to determine if arterial leukocyte filters during CPB improve clinical outcomes after valve surgery. METHODS A prospective analysis of all patients receiving only valve surgery with leukocyte arterial filters from June 1999 to June 2002 was compared with a case matched cohort during the same time period. Two hundred fifty patients were identified and compared with a cohort who did not have leukocyte filters used during CPB. The following study points were evaluated preoperatively and postoperatively: white blood cell count, platelet count, arterial blood gas, time to extubation, intensive care unit stay, and total length of hospital stay. RESULTS There were 500 patients in the study. The following valve operations were performed: 92 mitral valve replacements, 168 aortic valve replacements, 152 mitral valve repairs, 80 combined valve repair/replacements, and 8 tricuspid valve repairs, all evenly divided between the two treatment limbs. Patients with leukocyte filters had the following findings compared with nonfilter patients: The time to extubation 10.3 versus 16.2 hours (P = 0.009), postoperative respiratory quotient 407 versus 320 (P = 0.02), total length of stay 5.4 versus 7.2 days (P = 0.04). CONCLUSIONS The use of arterial leukocyte filters in patients undergoing valve surgery leads to earlier extubation, improved oxygenation, and a decreased length of stay. Leukocyte filters should be used during CPB for patients having valve surgery.
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Thrombotic occlusion of the aortic ostia of saphenous venous grafts early after coronary artery bypass grafting by using the Symmetry aortic connector system. J Thorac Cardiovasc Surg 2002; 124:397-9. [PMID: 12167803 DOI: 10.1067/mtc.2002.124236] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
BACKGROUND Utilization of bridging vein harvesting (BVH) of saphenous vein grafts (SVG) for coronary artery bypass grafting (CABG) results in large wounds with great potential for pain and infection. Endoscopic vein harvesting (EVH) may significantly reduce the morbidity associated with SVG harvesting. METHODS A prospective database of 200 matched patients receiving EVH and BVH was compared. The patients all underwent CABG done over a period of 4 months (April to August 2000). Patients were excluded if they had prior vein harvesting. RESULTS The EVH and BVH group included 100 patients each with similar demographics. The patients in the EVH group had significantly fewer wound complications, mean days to ambulation, and total length of stay (P <0.05). There was no difference in harvest time or vein injuries. CONCLUSION Endoscopic vein harvesting results in significantly fewer wound complications, decrease in days to ambulation, and the total length of stay. EVH is superior to BVH in patients undergoing CABG.
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Complex Cardiac Stab Wound. Proc (Bayl Univ Med Cent) 2001; 14:239-40. [PMID: 16369626 PMCID: PMC1305826 DOI: 10.1080/08998280.2001.11927769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Inhibition of the creatine kinase reaction decreases the contractile reserve of isolated rat hearts. THE AMERICAN JOURNAL OF PHYSIOLOGY 1995; 269:H1030-6. [PMID: 7573498 DOI: 10.1152/ajpheart.1995.269.3.h1030] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
To define the relation between phosphoryl transfer via creatine kinase (CK) and the ability of the intact beating heart to do work, we chemically inhibited CK activity and then measured cardiac performance under physiological and acute stress conditions. Isolated perfused rat hearts were exposed to iodoacetamide (IA) and subjected to one of three cardiac stresses: hypercalcemic (Ca2+ = 3 mM) buffer perfusion (n = 7), norepinephrine (2 mumol/min) infusion (n = 6), or hypoxic buffer perfusion (n = 5). IA decreased CK activity to near zero, measured in intact hearts by 31P magnetization transfer, and to 2% of control CK activity, measured in myocardial homogenates. The CK isoenzyme profile was unchanged, suggesting nonselective IA inhibition of all isoenzymes. Mitochondria isolated from IA-treated hearts had normal ADP:O ratios, state 3 respiratory rates, and unchanged acceptor and respiratory control ratios. Neither actomyosin adenosinetriphosphatase nor adenylate kinase activities were changed. After IA exposure, end-diastolic pressure, left ventricular developed pressure, and heart rate were unchanged for at least 30 min at physiological perfusion pressures, but large changes were observed during stress conditions. The increase in left ventricular developed pressure induced by hypercalcemic perfusion and by norepinephrine infusion decreased by 39 and 54%, respectively. During hypoxia, the rate of phosphocreatine depletion was decreased by 57%, left ventricular developed pressure declined, and end-diastolic pressure increased faster than in controls. These results show that inhibition of CK to < 2% of control activity by IA reduced contractile reserve by approximately 50%. We conclude that CK activity is essential for the expression of the full dynamic range of myocardial performance.
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