Is tranexamic acid safe in patients undergoing coronary endarterectomy?

BACKGROUND

Patients undergoing coronary endarterectomy during coronary artery bypass grafting (CABG) are at increased risk of perioperative myocardial infarction due to coronary intimal disruption. Data assessing the safety of the antifibrinolytic drug tranexamic acid (TA) in patients undergoing this procedure are lacking.

METHODS

From September 1997 to December 1999, 221 patients underwent nonemergency primary CABG with endarterectomy of the right coronary artery alone in 149, the left anterior descending in 35, or both right and left anterior descending in 27. TA was administered intraoperatively to 87 patients (TA group: average total dose 62 +/- 4.4 mg/kg; range 20 to 109 mg/kg), and was not administered to 134 patients (No TA group).

RESULTS

The patient characteristics of the 2 groups were similar. In-hospital mortality consisted of 2 patients in the TA group and 4 patients in the No TA group. Perioperative myocardial infarction rates were 2% and 5% in the TA and No TA groups, respectively (p = 0.49). The relative risk for any type of perioperative cardiac ischemic event in the TA group versus the No TA group was 0.77 (95% CI; 0.4, 1.2). Patients in the TA group had a significant reduction in postoperative chest tube drainage (685 versus 894 mL in the TA versus No TA groups, respectively) and in the use of fresh-frozen plasma (p = 0.03).

CONCLUSIONS

These results suggest that the clinical effectiveness of tranexamic acid in reducing postoperative blood loss in patients undergoing coronary endarterectomy is not associated with a higher incidence of myocardial ischemia-related complications.

The HeartSaver left ventricular assist device: an update

BACKGROUND

Ventricular assist devices have been shown to be effective as bridges to transplantation and recovery for patients with end-stage heart failure. Current technology has been limited because of the need for percutaneous connections with controllers. The HeartSaver ventricular assist device (VAD) (World Heart Corporation, Ottawa, Ontario, Canada) was developed with the intention of having a completely implantable, portable VAD system. The system consists of an electrohydraulic blood pump, internal and external battery power, and a transcutaneous energy transfer and telemetry unit that allows for power transmission through the skin. Control of the device may be achieved locally or remotely through a variety of communication systems.

METHODS

The device has been modified with the Series II preclinical version being available for in vitro (mock loop) and in vivo (bovine model) testing.

RESULTS

Seventeen Series II devices have been functional on mock loops or other testing trials for an accumulated 900 days of operation. There have been eight acute experiments using a bovine model to test various components as they have become available from manufacturing. Mean pump output was 10.4 +/- 1.1 L/min in full-fill/full-eject mode. Changes in the last 24 months include (1) cannula redesign for better port alignment and integration of tissue valves; (2) battery redesign to convert to new lithium-ion cells; (3) optimized infrared information and electromagnetic inductance energy transmission through various skin thicknesses and pigmentation; and (4) improved reliability of internal and external controller hardware and software.

CONCLUSIONS

Modifications have been required to optimize the HeartSaver VAD's performance. The final HeartSaver VAD design will be produced in the near future to allow for formal in vitro and in vivo testing before clinical implantation.

Implantable cardioverter-defibrillators and the pathologist: comment and cautionary notes

This paper briefly reviews the components of, the clinical uses of, the techniques to place, and the complications related to implantable cardioverter-defibrillators (ICDs). Information useful in the specific identification of ICDs is presented. A series of recommendations for the autopsy examination or postmortem explantation of ICDs by the pathologist is given. Because of the serious risk of injury to the pathologist possible with postmortem discharges of ICDs which have not been deactivated, and because of the risk of device explosion if the ICD is incinerated, a number of cautionary notes are provided. A brief case with occurrence of accidental postmortem discharge of an active ICD is also presented.

The patient with a pacemaker or related device

Patients with implanted pacemakers and ICDs can be safely managed for surgery and anaesthesia. Anaesthetic management of such patients should be planned first according to the patient's underlying medical status with particular emphasis on ventricular function and electrolyte balance. The anaesthetist must understand the various modes of pacemakers and ICDs available in the patient population. These devices are safe and well shielded form most electromagnetic interference in the operating room. Some precautions are nevertheless necessary. A magnet should not be placed routinely over a programmable pacemaker or ICD in the operating room, especially in the presence of electrocautery. Rate-responsive pacemakers should have rate adaptive modes disabled before surgery whenever possible. The mechanism of rate response should be known, so that inappropriate changes in heart rate can be avoided in the perioperative period if the rate responsive mode cannot for some reason be disabled. Antitachycardia pacemakers, should have the antitachycardia function disabled preoperatively. Methods for the provision of alternate emergency pacing should be available when dealing with patients at risk of bradyarrhythmias or pacemaker failure in the operating room. The anaesthetist should have a safe, practical plan of action that suites his/her experience and capabilities. ICDs should have automatic cardioverter-defibrillator functions disabled for surgery and external modes of cardioversion/defibrillation should be available.

Hybrid vigour and lamb production. 1. Reproductive performance of the purebred and crossbred matings

An experiment was conducted at Cowra Agricultural Research Station, New South Wales, to determine the importance of hybrid vigour to the productivity of crosses between Border Leicester and Merino sheep. In five years, 1963 to 1967, Border Leicester (BL) and Merino (M) rams were paddock-joined to a mixed flock of ewes of both breeds for five weeks in March-April. The results of these purebred and crossbred matings have been compared. Cummulative weekly raddle counts were similar for both purebred mating groups (BL x BL and M x M) and by the end of joining over 95 per cent of ewes in both groups had been raddled. When the mating data for the Border Leicester ewes were examined, Merino rams raddled fewer ewes than did Border Leicester rams. This breed difference between rams was significant for the number of ewes raddled by the end of both the first and second week of joining (P < 0.05) and the difference in favour of the Border Leicester rams was still apparent at the end of joining (97 vs. 86 per cent, not significant). The reproductive performance of the Merino ewes (M x M) was superior to that of the- Border Leicesters (BL x BL), with 1.05 vs. 0.93 lambs born per ewe joined. The Border Leicester flock had higher incidences of both dry ewes (63.7 vs. 79.3 per cent ewes lambing of those joined) and multiple births (1.47 vs. 1.33 lambs born per lambing ewe). Because of the difference in the mating activity of the two Border Leicester ewe flocks (M x BL vs. BL x BL), the most reliable estimates of the relative performance of purebred and crossbred matings were given by the number of lambs born per lambing ewe, and the number of ewes lambing to first service. The crossbred matings were superior for both characteristics, by 4.6 and 5.7 per cent respectively, but neither difference was statistically significant.

Hybrid vigour and lamb production. 2. Effects on survival and growth of first-cross lambs, and on wool and body measurements of hogget ewes

In an experiment at Cowra Agricultural Research Station, New South Wales, five drops of Border Leicester (BB), Merino (MM), Border Leicester x Merino (BM) and Merino x Border Leicester (MB) lambs have been compared to estimate hybrid vigour effects on lamb survival and growth, and on the wool and body measurements of ewe hoggets. Hybrid vigour has been estimated as the percentage superiority of the crossbreds 1/2(MB + BM) over the average of the purebred 1/2(BB + MM) flocks. Hybrid vigour was observed for lamb survival, with the crossbreds superior by 10 per cent in lambs weaned per lamb born (P < 0.05). The crossbred lambs were also heavier at birth (4 per cent) and weaning (6 per cent) and crossbred wether lambs were 11 per cent heavier at slaughter (all P < 0.05). The crossbred ewes were significantly superior to the average of the purebred flocks in both greasy (8 per cent) and clean fleece weight (12 per cent), liveweight (12 per cent) and chest depth (5 per cent) (all P < 0.05). There was no evidence that the crossbreds were superior in any component of wool production per unit area of the skin ; fibre length, fibre diameter or follicle density. Other evidence from this experiment indicates that the breeds and crosses differ in their susceptibility to pneumonia and that there may be heterosis for resistance. This situation could give rise to heterosis for production characters and the heterosis estimates obtained may only be applicable to first-cross flocks derived from Border Leicester studs which are susceptible to pneumonia. Lamb survival to weaning was higher for purebred Merinos (88 per cent) than for purebred Border Leicesters (73 per cent, P < 0.05). The Border Leicester lambs were heavier at all ages and in all years, although the magnitude of their superiority varied significantly between years (P < 0.05). This breed x year interaction was also significant for clean fleeca weight, but the average production of the two groups was similar over the five years. Variation, measured as the coefficient of variation, was generally lower within the crossbred flocks for those characters for which hybrid vigour effects were observed, but these differences were not statistically significant.

A study of mating behaviour of Merino rams

A pilot study of mating behaviour in a flock consisting of two breeds of ewes and three Merino rams is reported. Dominance-subordination reactions between rams caused large differences in the number of ewes served by each ram. The significance of these results practically and in relation to other work is discussed.