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Journal and News Scan

Source: EJCTS
Author(s): Hideo Ohuchi, Kenji Yasuda, Aya Miyazaki, Shin Ono, Yosuke Hayama, Jun Negishi, Kanae Noritake, Masanori Mizuno, and Osamu Yamada

412 Fontan patients were evaluated retrospectively for long-term correlations between postoperative haemodynamics and anticoagulant regimens with haemostatic events. Thrombo-embolic events were observed in 2.7% and haemorrhagic events in 4.4% of patients. Risk factors are analysed for both short- and long-term complications.

Source: Annals of Thoracic Surgery
Author(s): Shinji Otani, Bronwyn J. Levvey, Glen P. Westall, Miranda Paraskeva, Helen Whitford, Trevor Williams, David C. McGiffin, Rowan Walker, Solomon Menahem, Gregory I. Snell

This study evaluated outcomes of synchronous or delayed kidney Tx in patients with lung or heart-lung transplant.  Delayed living-donor kidney Tx was associated with favorable outcomes.  Synchronous cadaver kidney transplant at the time of heart-lung or lung transplant was clinically challenging.

Source: Annals of Thoracic Surgery
Author(s): Sara K. Pasquali, Xia He, Jeffrey P. Jacobs, Marshall L. Jacobs, Michael G. Gaies, Samir S. Shah, Matthew Hall, J. William Gaynor, Eric D. Peterson, John E. Mayer, Jennifer C. Hirsch-Romano

This study examined the utility/accuracy of an administrative database compared to the STS Congenital Database for the outcome of mortality, which is used to rank quality.  The administrative database had substantially lower volume and mortality numbers than the STS Database, resulting in ranking differences of 5 or more places for 24% of hospitals.

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.