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Journal and News Scan
Using data from the Australian Cardiac Surgical Database, the authors provide further information regarding acute kidney damage after cardiac surgery. This study has added to the evidence that preoperative impairment, IABP use, red cell transfusion and infective endocarditis are predictive factors. It remains to be determined what therapies can be instituted to reduce changes in renal function in future clinical trials.
The rate of cerebral embolism in patients with acute infective endocarditis (AIE) was about one quarter on CT scanning, with about one third having silent emboli. This had an adverse impact on survival. Haemorrhagic transformation was low. The authors indicate CT scanning should be routine for all patients with AIE.
This is one of the excellent videos available free in full at www.annalscts.com
Massive left hemothorax is a rare and dramatic complication of acute type B aortic dissection. The primary endpoint is to treat the aortic rupture, stop the bleeding and stabilize the hemodynamic status, with the aim to prevent mortality and major cardiac, cerebral, visceral and renal complications. Thoracic endovascular repair (TEVAR) is the most frequent management, although its planning, in these emergent patients, may be very difficult and sub-optimal imaging may result at post-operative examination (CT and MRI). In case of TEVAR is not the definitive treatment of the aortic disease, a second stage surgical management can be performed in elective status, in a patient with a total clinical recover. In acute and dramatic circumstances, like ruptured type B dissection, TEVAR is a valid and suitable bridge procedure to open surgery, reducing the overall risk for mortality and major complications.
This report on 127 pts with atypical pulmonary carcinoid evaluated clinical and pathological prognostic features. Recurrence developed in 25% of pts during follow-up, with sublobar resection being the only independent predictor. Survival was related only to distant recurrence on multivariable analysis. The authors recommend complete standard anatomical resection with radical lymphadenectomy as a the standard of care.
In this study, the authors identify a number of markers in cardiac stem cells obtained from 38 patients undergoing coronary artery bypass grafting which appear to predict positive myocardial remodelling at 12 months following surgery
This large-scale study evaluated kidney function postoperatively and at 1 year after either on-pump or off-pump isolated first time CABG. Nearly 3000 pts were enrolled over a 2 year period. Outcomes were a >50% increase in creatinine within 30 days of operation (AKI) and >20% loss of GFR at 1 year. Off-pump bypass was associated with a lower incidence of AKI (17.5% vs 20.8%), but the rates of loss of kidney function at 1 year were similar (17.1% vs 15.3%).
Coronary artery bypass grafting (CABG) has been considered the standard of care for patients with three-vessel disease (3VD), but long-term comparative results from randomized trials of CABG vs. percutaneous coronary intervention (PCI) using drug-eluting stents (DES) remain limited. Five-year results of patients with 3VD treated with CABG or PCI using the first-generation paclitaxel-eluting DES suggest that CABG should remain the standard of care as it resulted in significantly lower rates of death, MI, and repeat revascularization, while stroke rates were similar. For patients with low SYNTAX scores, PCI is an acceptable revascularization strategy, although at a price of significantly higher rates of repeat revascularization.
- Patients with de novo 3VD or left main disease were randomly assigned to PCI with the paclitaxel-eluting first-generation stent or CABG in the SYNTAX trial.
- This pre-specified analysis presents the 5-year outcomes of patients with 3VD (n = 1095).
- The rate of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in patients with PCI compared with CABG (37.5 vs. 24.2%, respectively; P < 0.001).
- Percutaneous coronary intervention as opposed to CABG resulted in significantly higher rates of the composite of death/stroke/myocardial infarction (MI) (22.0 vs. 14.0%, respectively; P < 0.001), all-cause death (14.6 vs. 9.2%, respectively; P = 0.006), MI (9.2 vs. 4.0%, respectively; P = 0.001), and repeat revascularization (25.4 vs. 12.6%, respectively; P < 0.001); however, stroke was similar between groups at 5 years (3.0 vs. 3.5%, respectively; P = 0.66).
- Results were dependent on lesion complexity (P for interaction = 0.12); in patients with a low (0–22) SYNTAX score, PCI vs. CABG resulted in similar rates of MACCE (33.3% vs. 26.8%, respectively; P = 0.21) but significantly more repeat revascularization (25.4% vs. 12.6%, respectively; P = 0.038), while in intermediate (23–32) or high (≥33) SYNTAX score terciles, CABG demonstrated clear superiority in terms of MACCE, death, MI, and repeat revascularization.
- Differences in MACCE between PCI and CABG were larger in diabetics [hazard ratio (HR) = 2.30] than non-diabetics (HR = 1.51), although the P for interaction failed to reach significance for MACCE (P for interaction = 0.095) or any of the other endpoints.
The authors of this paper prospectively studied stroke after aortic valve replacement (AVR) in patients with aortic stenosis (AS) and >65years old. Neurological status was assessed pre- and postoperatively assessed by neurologists, postoperatively by MRI and strokes were evaluated according to the National Institutes of Health Stroke Sscale. The authors show that the incidence of clinical stroke after AVR was higher than for the same cohort in the STS database. Moreover, sub-clinical infarctions were detected in >50% of all AVRs. Clinical stroke was associated with longer hospital stay and higher mortality.
LVR using endobronchial therapies remains experimental. This multicenter study tested LVR coils in 60 pts for safety and efficacy. There were a total of 18 serious adverse events. At 6 and 12 mos, dyspnea scores decreased 11%, 6 min walk increased 30-50 m, and FEV1 increased 0.11 L. Pts with either heterogeneous or homogeneous emphysema appeared to improve.
This is a nice video that demonstrates what items are required to safely perform an emergency resternotomy.
Might be a nice video to show to your ICU nurses or those who might be required to assist in an emergency resternotomy.
There is further information on emergency resternotomy at www.csu-als.com