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Journal and News Scan

Source: Annals of Thoracic Surgery
Author(s): Colleen G. Koch, Edmunds Z. Reineks, Anne S. Tang, Eric D. Hixson, Shannon Phillips, Joseph F. Sabik, J. Michael Henderson, Eugene H. Blackstone

The frequency of blood draws after cardiac surgery is rarely tracked.  This study tracked such activity for a 6-month period at the Cleveland Clinic.  In over 1,800 pts, the average number of tests requiring blood was 115.  Total average blood volume removed was 454 ml.  The average for complex procedures was 653 ml.  This system is ripe for process improvement.

Source: Annals of Thoracic Surgery
Author(s): James J. Pilla, Kevin J. Koomalsingh, Jeremy R. McGarvey, Walter R.T. Witschey, Larry Dougherty, Joseph H. Gorman, Robert C. Gorman

This interesting article mapped myocardial remodeling in swine after induced MI using serial 3D MRI imaging.  Principal strain magnitude and angle were measured, and demonstrated progressive decrease in magnitude and angle rotation away from the site of injury, resulting in adverse remodeling and decreased contractility. 

Source: Journal of Thoracic and Cardiovascular Surgery
Author(s): Vincenzo Tarzia, Giacomo Bortolussi, Roberto Bianco, Edward Buratto, Jonida Bejko, Massimiliano Carrozzini, Marco De Franceschi, Dario Gregori, Dario Fichera, Fabio Zanella, Tomaso Bottio, Gino Gerosa

The authors retrospectively analyze outcomes for patients placed on ECMO for cardiogenic shock, and separately analyze the patients depending on whether the ECMO support was for isolated acute cardiogenic shock or for acute-upon-chronic cardiogenic shock.  Over a 4-year period, 37 (58%) patients fell into the isolated acute category, and 27 (42%) in the acute-upon-chronic category.  Overall 30-day survival was 80%, with a hospital discharge rate of 59%.  Not surprisingly, the only patients who recovered cardiac function were in the isolated acute group.  The acute-upon-chronic category required bridging, either to heart transplantation or mechanical circulatory support.

Source: Annals of Thoracic Surgery
Author(s): Alberto Forteza, Jorge Centeno, Victor Ospina, Inés García Lunar, Violeta Sánchez, Enrique Pérez, María Jesús López, José Cortina

This retrospective review of outcomes after reconstruction of the intervalvular fibrous trigone combined with aortic and mitral valve replacement  tracked patients who were operated upon for either severe endocarditis (n=26) or severe calcification (n=14) involving the trigone.  The David Technique for reconstruction was used, and the operative mortality for these complex operations was 15% and 7%, respectively.  Despite high operative risk and complexity, the authors from Madrid show that this operation can be performed with respectable morbidity and mortality rates.

Source: European Respiratory Journal
Author(s): Masoud Dara, Giovanni Sotgiu, Richard Zaleskis and Giovanni Battista Migliori

The increasing prevalence of multidrug-resistant and extensively drug-resistant tuberculosis (MDR/XDR-TB) in some countries is alarming.  When few therapeutic options remain, old procedures need to be re-evaluated based on evidence, specially, surgery. Surgery combined with medical treatment has the chance of cure if the lesions are limited to some lobes or segments in one lung and the patient is diagnosed as early as possible. From a public health perspective, treating existing drug-resistant cases as soon as possible with all possible means, including surgery, can stop transmission of TB infections within the community.

Source: Journal of Cardiothoracic Surgery
Author(s): Simon Schopka, Claudius Diez, Daniele Camboni, Bernhard Floerchinger, Christof Schmid and Michael Hilker

Comparing 714 on pump and 714 off pump CABG patients, the investigators investigated the incidence of Acute Kidney Injury (AKI) and whether cardiopulmonary bypass time and or duration were independent contributors to AKI.  The investigators concluded that there are no differences in the incidence of AKI during  CABG surgery employing CPB. Use of off-pump bypass for patients with pre existing AKI may avoid further injury.

As the debate rages on about which technique is superior, several concerns come to mind.

1. When comparing on pump to off pump most studies do not look at the perfusion circuit as a whole to determine prime volume, which contributes to excessive hemodilution and is associated with AKI and increased transfusions.

2. Most studies do not evaluate the use of intra-aortic filtration for the capture of atheroma during aortic cross clamp application and removal. These potential embolic events are known contributors to renal, neurologic, and other sequelae.

3. Most studies do not include data such as continuous cardiac output measurements or cerebral oximetry measurements during off pump CABG. Cardiac anesthesiologists are excellent clinicians that can give the surgeon whatever systemic pressure is desired, while in reality, perfusion may be severely compromised.

4. During on pump surgery, would it be beneficial to perform continuous veno-veno hemofiltration with bicarb based solutions to clear pro inflammatory mediators and maintain physiologic homeostasis. This is more easily achieved in the on pump group and it perhaps a worthwhile addition to the CPB circuit to investigate in regards to reducing post op AKI.



Source: European Journal of Cardio-Thoracic Surgery
Author(s): Castelvecchio S, Menicanti L, Ranucci M

This study describes the development and validation of a risk score for post-operative mortality in patients undergoing surgical ventricular reconstruction (SVR). The study included data on 525 patients who underwent SVR at a single institution since 2001. Most patients (93%) had cocomitant CABG and 27% of patients had concomitant mitral surgery. In-hospital or 30-day mortality occurred in 9.1% of patients. Risk factors included in the risk score which was developed using mulitvariate logistic regression include the ACEF score (based on the patients age, creatinine and ejection fraction), atrial fibrillation, NYHA III/IV symptoms and concomitant mitral surgery. On internal bootstrapped validation, the new model demonstrated improved discrimination and calibration compared to the ACEF score alone. 

Source: JAMA
Author(s): Anne-Marie Schjerning Olsen; Gunnar H. Gislason; Patricia McGettigan; Emil Fosbøl; Rikke Sørensen; Morten Lock Hansen; Lars Køber; Christian Torp-Pedersen; Morten Lamberts

This study evaluated potential safety concerns of using NSAIDS in combination with antithrombotic agents 30 days or more after MI.  The population studied was comprised of nearly 62,000 Danish patients.  Use of NSAIDs at any time doubled the risk of a bleeding episode and increased the risk of a major cardiovascular event by 40%.  The NSAIDs risks were present even after short-term NSAIDS use. 

Source: Circulation
Author(s): Richard P. Whitlock; Jeff S. Healey; David R. Holmes

This is an excellent summary of the pros and cons of LAA occlusion for stroke prevention in non valvular AF. The authors consider the evidence for both, and expand on the limitations of some of the cited studies' designs and the lack of a registry.  As is well established, a registry could be useful in determining long term efficacy such as is found in the The Transcatheter Valve Therapy registry for surveillance of transcatheter aortic valve replacement.

Source: Pub Med
Author(s): Montoya JP1, Shanley CJ, Merz SI, Bartlett RH.

Resently confronted with the problem of plasma leakage out of the gas exhaust port of the oxygenator, necessesatatting changing of the oxygenator several times in 48 hours. We noted that the the plasma in the discarded oxygenator that had seperated was milky white in color and we checked for hyperlipidemia which was affirmed. In addition, propofol was being used and the patient had elevated glucose levels. An insulin drip was started and the propofol replaced with versed. The subsequent oxygenator survived 6 hours and hte next over 24 hours indicating improvment. Measured lipid levels wer also lower. 

Believeing that the root couse was the hyperlipidemia but not having confirmation of this, I contacted an engineering friend that works with these types of hollow fibers. He subsequently forwarded me this article.

The investigators, under experimental conditions, created plasma leakage in the hollowfiber oxygenators and conclude that the absorbtion of phospholipids leads to the formation of a hydrophilic layer over the surface of the membrane which is hydrophobic leading to plasma leakage.