Showing papers in "European Journal of Cardio-Thoracic Surgery in 2011"
TL;DR: The comprehensive assessment of frailty is an additional tool to evaluate elderly patients adequately before cardiac surgical interventions and may facilitate a more accurate risk scoring in elderly high-risk patients scheduled for conventional cardiac surgery or trans-catheter aortic valve replacement.
Abstract: Objective Cardiosurgical operative risk can be assessed using the logistic European system for cardiac operative risk evaluation (EuroSCORE) and the Society of Thoracic Surgeons (STS) score. Factors other than medical diagnoses and laboratory values such as the 'biological age' are not included in these scores. The aim of the study was to evaluate an additional assessment of frailty in routine cardiac surgical practice. Methods 'The comprehensive assessment of frailty' test was applied to 400 patients≥74 years who were admitted to our centre between September 2008 and January 2010. For comparison, the STS score and the EuroSCORE were calculated. The primary end point was the correlation of Frailty score to 30-day mortality. A total of 206 female and 194 male patients were included. Results Median Frailty score was 11 [7,15]. Median of logistic EuroSCORE was 8.5% [5.8%; 13.9%]. Median of STS score was 3.3% [2.1%; 5.1%]. There were low-to-moderate albeit significant correlations of Frailty score with STS score and EuroSCORE (p Conclusions The comprehensive assessment of frailty is an additional tool to evaluate elderly patients adequately before cardiac surgical interventions. The Frailty score combines characteristics of the Fried criteria [1], of patient phenotype, of his physical performance and laboratory results. Further analysis on a larger patient population is warranted. A combination of the new Frailty score and the traditional scoring systems may facilitate a more accurate risk scoring in elderly high-risk patients scheduled for conventional cardiac surgery or trans-catheter aortic valve replacement.
297 citations
TL;DR: Thorough analysis of the recent literature shows a growing amount of evidence supporting the hemodynamic theory of aortopathy in patients with BAV disease, and acknowledges that hemodynamics plays an important role in the development of this disease process.
Abstract: Although there is adequate evidence that bicuspid aortic valve (BAV) is an inheritable disorder, there is a great controversy regarding the pathogenesis of dilatation of the proximal aorta. The hemodynamic theory was the first explanation for BAV aortopathy. The genetic theory, however, has become increasingly popular over the last decade and can now be viewed as the clearly dominant one. The widespread belief that BAV disease is a congenital disorder of vascular connective tissue has led to more aggressive treatment recommendations of the proximal aorta in such patients, approaching aortic management recommendations for patients with Marfan syndrome. There is emerging evidence that the 'clinically normal' BAV is associated with abnormal flow patterns and asymmetrically increased wall stress in the proximal aorta. Recent in vitro and in vivo studies on BAV function provide a unique hemodynamic insight into the different phenotypes of BAV disease and asymmetry of corresponding aortopathy even in the presence of a 'clinically normal' BAV. On the other hand, there is a subgroup of young male patients with BAV and a root dilatation phenotype, who may present the predominantly genetic form of BAV disease. In the face of these important findings, we feel that a critical review of this clinical problem is timely and appropriate, as the prevailing BAV-aortopathy theory undoubtedly affects the surgical approach to this common clinical entity. Thorough analysis of the recent literature shows a growing amount of evidence supporting the hemodynamic theory of aortopathy in patients with BAV disease. Data from recent studies requires a reevaluation of our overwhelming support of the genetic theory, and obliges us to acknowledge that hemodynamics plays an important role in the development of this disease process. Given the marked heterogeneity of BAV disease, further studies are required in order to more precisely determine which theory is the 'correct' one for explaining the obviously different types of BAV-associated aortopathy.
206 citations
TL;DR: Maintaining perfusion pressure at physiologic levels during normothermic CPB (80-90 mm Hg) is associated with less early postoperative cognitive dysfunction and delirium, and this perfusion strategy neither increases morbidity, nor does it impair organ function.
Abstract: Objective: Patients undergoing cardiac surgery procedures are thought to be at risk of early neuropsychological deficits and delirium. Regional cerebral hypoperfusion may play a role in the etiology of this complication. We hypothesized that low systemic perfusion pressure during cardiopulmonary bypass (CPB) would correlate with early postoperative cognitive dysfunction in on-pump patients. Methods:In this prospective, randomized, single-center trial, we assigned 92 patients scheduled for elective or urgent coronary artery bypass grafting (CABG) to high-pressure (HP: 80—90 mmHg, n = 44) or low-pressure (LP: 60—70 mmHg, n = 48) perfusion groups during CPB. Patients with prior cerebrovascular or psychiatric disorders were excluded. Primary end point was the cognitive outcome as measured by Mini-Mental-Status examination before and 48 h after surgery. Results: Patients’ pre- and intra-operative characteristics did not differ between groups. Significantly more patients in the LP group developed postoperative delirium than in the HP group (LP 13%. vs HP 0%, p = 0.017). The postoperative drop in Mini-Mental-Status scores was significantly greater in the LP group (LP 3.9 6.5 vs HP 1.1 1.9; p = 0.012). No group differences were detected in cerebral oxygenation measured by near-infrared spectroscopy during CPB. The LP group’s postoperative arterial lactate concentration in the intensive care unit was significantly higher as compared with the HP group (LP 2.0 1.1 mmol l 1 vs HP 1.4 0.6 mmol l 1 ; p < 0.001). We observed no differences between the groups in any other postoperative clinical, functional, or laboratory parameters. Conclusion: Maintaining perfusion pressure at physiologic levels during normothermic CPB (80—90 mmHg) is associated with less early postoperative cognitive dysfunction and delirium. This perfusion strategy neither increases morbidity, nor does it impair organ function. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
169 citations
TL;DR: Mitral valve repair for IMR is associated with better short-term and long-term survival compared to mitral valve replacement and, in the absence of any published randomized studies, mitral procedure selection should be individualized.
Abstract: The optimal surgical strategy for the management of ischemic mitral regurgitation (IMR) is still debated. The purpose of this study was to perform a meta-analysis summarizing the evidence favoring one technique over another (repair vs replacement). A search of the English literature in PubMed was performed using 'ischemic mitral regurgitation' and 'repair or replacement or annuloplasty' in the title/abstract field. Articles were excluded if they lacked a direct comparison of repair versus replacement, or used Teflon/pericardial strip or suture annuloplasty in >10% of the repairs. Nine articles were selected for the final analysis. All studies except one were relatively recent (2004-2009). The patient characteristics between treatment groups were similar across studies. All studies excluded patients with degenerative etiology and used a rigorous definition of IMR. Most patients had concomitant coronary artery bypass graft. In the patients with mitral valve replacement, at least the posterior and, in many cases, the entire subvalvular apparatus were preserved. Mean ejection fraction and proportion of patients with severe ventricular dysfunction were similar between the repair and replacement groups. The odds ratios for the studies, comparing replacement to repair, ranged from 0.884 to 17.241 for short-term mortality and the hazard ratios ranged from 0.677 to 3.205 for long-term mortality. There was a significantly increased likelihood of both short-term mortality (summary odds ratio 2.667 (95% confidence interval (CI) 1.859-3.817)) and long-term mortality (summary hazard ratio 1.352 (95% CI 1.131-1.618)) for the replacement group compared to the repair group. Based on the meta-analysis of the current relevant literature, mitral valve repair for IMR is associated with better short-term and long-term survival compared to mitral valve replacement. Our conclusion should be interpreted in the context of the inherent limitations of a meta-analysis of retrospective studies including heterogeneity of patient characteristics, which may have influenced the physician's decision to perform mitral valve repair or replacement. In the absence of any published randomized studies, mitral procedure selection should be individualized.
162 citations
TL;DR: Clinical manifestations of pulmonary sequestration varied and preoperative diagnosis was often incorrect, and more research on the clinical characteristics ofmonary sequestration should be carried out to improve the preoperativediagnosis rate.
Abstract: Objective: Pulmonary sequestration is a congenital lung malformation, which is often misdiagnosed as lung cancer, pulmonary cysts, mediastinal tumors, etc. Therefore, more research on the clinical characteristics of pulmonary sequestration should be carried out to improve thepreoperativediagnosisrate.Methods:Thestudyusedwasa retrospective analysisof2625cases ofpulmonarysequestrationwelldocumented in the Chinese National Knowledge Infrastructure from 1998 to 2008. Analysis was performed on the patients’ age, gender, symptom, chest computed tomography (CT) scan, chest radiograph, lesion localization, arterial supply, venous drainage, and incorrect preoperative diagnosis. Results: A total of 2625 cases of pulmonary sequestration was reported in the Chinese National Knowledge Infrastructure from 1998 to 2008, and themale:female ratiowas1.58:1.Thesymptomsofpulmonarysequestrationwerecough,sputum,fever, hemoptysis,andchestpain,with13.36% of patients being asymptomatic. Chest CTscan showed mass lesions (49.01%), cystic lesions (28.57%), cavitary lesions (11.57%), and pneumonic lesions (7.96%). The sequestration was mainly located in the lower lobe, primarily in the left posterior basal segment (66.43%) and in the right posterior basal segment (20.16%). Pulmonary sequestrations were divided into two types, intralobar sequestration (83.95%) and extralobar sequestration (16.05%). Bilateral sequestrations were rare — only three cases had been reported. The arterial supply was mainly provided by branches of thoracic aorta (76.55%) and abdominal aorta (18.47%). The mean incorrect preoperative diagnosis rate was as high as 58.63%. A comparison between pediatric and adult patients indicated that the subtype ratio (intralobar/extralobar) was higher in the adult group than that in the pediatric group (P < 0.001). Conclusions: Clinical manifestations of pulmonary sequestration varied and preoperative diagnosis was often incorrect. To improve the preoperative diagnosis rate, we should take full advantage of symptoms, image performance, and localization characteristics. A certain early-onset age, recurrent pneumonias, mass or cyst lesion located in the lower lobe, and aberrant arterial supply are indicators for the diagnosis. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
153 citations
TL;DR: The data suggest that 6 months after LVAD implantation it is possible to observe an important reduction of PH and evaluate the potential transplantability of patients, and longer support does not add any effect of LVAD on PH.
Abstract: Objective: Conflicting data still exist concerning the reversibility of secondary severe ‘fixed’ pulmonary hypertension (PH) by the use of left ventricular assist device (LVAD) support in terms of time necessary to provide a bridge to ‘transplantability’. Methods: We retrospectively reviewed 145 patients with heart failure and severe PH treated by LVAD support between 2000 and 2009. There were 133 men (91.7%) and 12 women(8.3%)withameanageof52.95 12.01years.PatientsweredividedintotwogroupsdependingonpreoperativePHreversibility.FixedPH was defined by a mean pulmonary arterial pressure (mPAP) >25 mmHg, a pulmonary vascular resistance (PVR) >2.5 Wood Unit (WU) and a transpulmonary gradient (TPG) >12 mmHg, despite pharmacological treatment. Results: Fifty-six patients had fixed PH (group A) and 89 reversible PH (group B). Only 27 patients of group A underwent right heart catheterization evaluation during LVAD support; the remaining 29 patients had other contraindications to heart transplantation (HTx). The 27 patients were divided into three subgroups on the basis of examination time during LVAD support: 12 months (10 patients).The mPAP, PVR, and TPG decreased significantly during LVAD support (mPAP, 37.26 6.35 mmHg vs 21.00 7.51 mmHg, p = 0.007; PVR, 3.49 1.47 WU vs 1.53 0.66 WU,p = 0.000;andTPG,15.04 5.22 mmHgvs 7.78 3.21 mmHg,p = 0.019). Asignificantreductionof allparameters wasobserved during the first 6 months and later on there was no further decrease. There were no significant differences between the three subgroups (mPAP, p = 0.680; PVR, p = 0.723; and TPG, p = 0.679) in terms of time of reversibility. LVAD support allowed 19 patients to be transplanted. Conclusions: Patients with fixed PH can be treated with LVAD support. Our data suggest that 6 months after LVAD implantation it is possible to observe an important reduction of PH and evaluate the potential transplantability of patients. Longer support does not add any effect of LVAD on PH.
148 citations
TL;DR: Findings support a conservative surgical approach to circumvent this life-threatening situation and total arch repair was associated with greater morbidity and mortality compared with hemiarch repair in acute DeBakey type I aortic dissection.
Abstract: Objective: In acute DeBakey type I aortic dissection, it is still controversial whether to perform extended aortic replacement to improve longterm outcome or to use a conservative strategy with ascending aortic and hemiarch replacement to palliate a life-threatening condition. Methods:Between1999 and 2009,188 consecutive patients (93women;mean age, 57.4 11.7 years) with acuteDeBakey type I aorticdissection underwent hemiarch (Hemiarch group; n = 144) or total arch replacement (Total arch group; n = 44) in conjunction with ascending aorta replacement. Clinical outcomes were compared after adjustment for baseline characteristics using inverse-probability-of-treatment weighting. Results: Median follow-up was 47.5 months (range 0—130.4 months) and was 92.0% (n = 173) complete. Five-year unadjusted survival and permanent-neurologic-injury-free survival rates were 65.8 8.3% and 43.1 9.7% in the Total arch group, and 83.2 3.3% and 75.2 4.0% in the Hemiarch group, respectively (P = 0.013 and 55 mm) were similar for both groups (HR 0.33, 95% CI 0.08—1.43; P = 0.14). Conclusions: Total arch repair was associated with greater morbidity and mortality compared with hemiarch repair in acute DeBakey type I aortic dissection. Rates of aortic re-operation or aortic dilatation were not significantly different between the two surgical strategies. These findings support a conservative surgical approach to circumvent this life-threatening situation. Crown Copyright # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
144 citations
TL;DR: Indications and contraindications for ECLS, the management and control of a wide range of parameters related to the extracorporeal circulation, as well as the necessary equipment are described.
Abstract: Summary Extracorporeal life support (ECLS) is one of the recent fields in cardiac surgery which has improved significantly the quality of patient care in acute or chronic end-stage heart disease. The safe use of this new technology requires many different prerequisites which are summarized in this position article. It includes the necessary personnel and their qualifications, the structural assumptions, the required equipment, and the parameters which have to be monitored for the safe usage of these devices. In addition, indications and contraindications for ECLS, the management and control of a wide range of parameters related to the extracorporeal circulation, as well as the necessary equipment are described. Quality assurance and education are also described in this position article. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
129 citations
TL;DR: The findings of this systematic review of the published literature and meta-analysis support the use of radial artery in preference to saphenous vein conduits for coronary artery bypass surgery.
Abstract: The internal thoracic artery is the most effective conduit for coronary artery bypass surgery; however, most patients have multivessel disease and require additional saphenous vein or radial artery grafts. In this systematic review of the literature and meta-analysis, we aim to compare reported patency rates for these conduits and explore if differences are homogeneous across follow-up intervals. A literature search was performed using Embase, Medline, Cochrane Library, Google Scholar and randomised controlled trial databases to identify studies published between 1965 and October 2009. All studies reporting angiographic comparison of saphenous vein and radial artery conduit patency were included, irrespective of language. The end point was angiographic graft patency stratified over different follow-up intervals. Meta-analysis was performed according to recommendations from the Cochrane Collaboration and Meta-analysis Of Observational Studies in Epidemiology guidelines. We used a random-effect model and the odds ratio as the summary statistic. A total of 35 studies were identified. They reported early patency (≤ 1 year, 6795 grafts), medium-term patency (1-5 years, 3232 grafts) and long-term patency (>5 years, 1157 grafts). Significant variation of comparative patency existed across different follow-up intervals. Early saphenous vein patency was similar to radial artery patency with odds ratio of 1.04 (95% confidence interval 0.68-1.61). Medium-term saphenous vein patency, however, deteriorated significantly (odds ratio 2.06, 95% confidence interval 1.29-3.29). Similarly, long-term patency was better for radial artery conduits (odds ratio 2.28, 95% confidence interval 1.32-3.94). Heterogeneity was due to angiographic patency characteristics and related to risk of bias. In conclusion, the findings of this systematic review of the published literature and meta-analysis support the use of radial artery in preference to saphenous vein conduits for coronary artery bypass surgery.
127 citations
TL;DR: Systemic mild-to-moderate hypothermia that is adapted to the duration ofcirculatory arrest is a simple, safe, and effective method of organ protection and can be recommended in routine aortic arch surgery with circulatory arrest and cerebral perfusion.
Abstract: OBJECTIVES: Antegrade cerebral perfusion makes deep hypothermia non-essential for neuroprotection; therefore, there is a growing tendency to increase the body temperature during circulatory arrest with selective brain perfusion. However, very little is known about the clinical efficacy of mild-to-moderate hypothermia for ischemic organ protection during circulatory arrest. The aim of this study was to evaluate the safety and efficiency of mild-to-moderate hypothermia for lower-body protection during aortic arch surgery with circulatory arrest and antegrade cerebral perfusion. METHODS: Between January 2005 and December 2009, a total of 347 patients underwent non-emergent arch surgery. In all patients, the systematic cooling was adapted to the expected time of circulatory arrest, and cerebral perfusion was performed at a constant blood temperature of 28 °C. There were 40 cardiac or aortic re-operations, 312 patients had concomitant aortic valve or root surgery, and 10 patients had replacement of the descending aorta. All examined data were collected prospectively. RESULTS: The duration of circulatory arrest and the deepest rectal temperature were 18 ± 11 min (range, 6–70 min) and 31.5 ± 1.6 °C (range, 26.0–35.0 °C) for all 347 patients, and 34 ± 12 min (range, 17–70 min) and 29.9 ± 1.7 °C (range, 26.0–34.6 °C) for 77 patients having total/subtotal arch replacement. The maximum serum lactate level on the first postoperative day was, on average, 2.3 ± 1.2 mmol l −1 . In the statistical analysis, no association between the duration of temperature-adapted circulatory arrest and lactate, creatinine, or lactate dehydrogenase levels after surgery could be demonstrated. The 30-day mortality was 0.9%. Permanent neurological deficit or temporary dysfunction occurred in three (0.9%) and eight (2.3%) patients, respectively. No paraplegia and no hepatic failure were reported; however, mesenteric ischemia occurred in one patient with severe stenosis of the celiac and upper mesenteric arteries. Temporary dialysis was necessary primarily after surgery in five patients. All of them underwent hemiarch replacement only, and four patients had an increased creatinine level before surgery. CONCLUSION: Systemic mild-to-moderate hypothermia that is adapted to the duration of circulatory arrest is a simple, safe, and effective method of organ protection and can be recommended in routine aortic arch surgery with circulatory arrest and cerebral perfusion.
124 citations
TL;DR: The incidence of silent cerebral embolic lesions after TAVI is significantly higher compared with the standard surgical AVR and the number of emboli is similar in the TF and TA groups but the volume tended to be higher in the TA group, but there is no clinical impact of those lesions.
Abstract: Objective: Cerebral embolization during trans-catheter aortic valve implantation (TAVI) has not been assessed clearly in the literature. Therefore, we compared the rate of cerebral embolisms with diffusion-weighted magnetic resonance imaging (DWI) in transfemoral (TF) and trans-apical (TA) approaches. Method: Eighty patients benefited from TAVI between January 2008 and June 2010. Out of these, 35 were included in the study. Twenty-one were TF (group 1) and 14 TA (group 2). During the same period, 285 patients benefited from a conventional aortic valve surgery (aortic valve replacement (AVR)). Thirteen of these were also analyzed and considered as the control group (group 3). We systematically performed a DWI the day before the procedure and 48h after. DWI studies were blindly analyzed by a neuroradiologist, and all patients had a clinical neurological assessment before and after the procedure, according the National Institutes of Health Stroke Scale (NIHSS). Results: Thirty-two patients in the TAVI group had new cerebral lesions: 19 in the TF group and 13 in the trans-apical group (p=NS). Mean number of embolic lesions per patient was 6.6 in group I and 6.0 in group II (p=NS). Mean volume of embolic lesions was 475.0mm(3) in group I and 2170.5mm(3) in group II (p=NS). In group III, one patient had one new cerebral lesion (p<0.05 vs TAVI) of 36.5mm(3) (p=NS vs TAVI). All patients were neurologically asymptomatic. Conclusions: The incidence of silent cerebral embolic lesions after TAVI is significantly higher compared with the standard surgical AVR. The number of emboli is similar in the TF and TA groups but the volume tended to be higher in the TA group. However, there is no clinical impact of those lesions.
TL;DR: A complete, prospective analysis of complications occurring during transvascular and trans-apical implantations with two different prostheses is reported, indicating that complications with TAVI may be avoided by proper patient selection and skillful management.
Abstract: Objective: Trans-catheter aortic valve implantation (TAVI) technology is rapidly evolving, with 412 procedures having been performed at our institution. Herein, we report a complete, prospective analysis of complications occurring during transvascular and trans-apical implantations with two different prostheses. Methods: Between June 2007 and June 2010, 412 patients (258 female, mean age 80.3 7.2 years, logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) 20.2% 13.0%) underwent TAVI through either a retrograde (n = 252 transfemoral, n = 28 transaxillary, and n = 5 transaortic) or antegrade (n = 127 trans-apical) approach at our institution. The trans-apical access was chosen only in cases where transvascular implantation was not possible. As many as 283 CoreValve and 129 Edwards Sapien prostheses were implanted. Results: Thirty-day survival was 90.9%. Vascular complications occurred in 42 patients (10.2%). In four patients, lethal aortic root (n = 3) or abdominal (n = 1) aortic rupture occurred. Pericardial effusion developed in 53 patients (12.8%), which resulted in cardiac tamponade in 12 patients (2.9%). Twenty-three patients (5.6%) with valve malplacement were treated interventionally. In five patients (1.2%), emergency institution of cardiopulmonary bypass was required during the procedure for temporary support; all patients survived. Seventeen patients underwent re-intervention on the catheter valve (4.1%). Conclusions: With growing experience, complications with TAVI may be avoided by proper patient selection and skillful management. Other complications, when they occur, require a specific treatment algorithm to avoid delay in decision making. A considerable number of complications after TAVI require surgical treatment. Therefore, the ideal environment for TAVI procedures is a hybrid operating room, where a multidisciplinary team of surgeons, cardiologists, and anesthesiologists is best fitted to meet the current needs associated with TAVI technology. A reduction in complications was seen after 300 cases. This finding attests to the complexity of the procedure in addition to the experience required to reduce the incidence of complications. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: A simple risk stratification score is developed that can separate, preoperatively, patients into risk groups with markedly different rates of severe postoperative bleeding.
Abstract: Objective:Wehavedevelopedariskstratificationscoretoidentifycardiacsurgicalpatientsathigherriskofseverepostoperativebleedingtoaida decisionofwhethertouseaspecificinterventionpreoperatively.Methods:Weprospectivelycreatedadatabaseof11 592consecutivepatients,who underwent cardiac surgery with cardiopulmonary bypass. An adverse outcome was formally defined as a mean blood loss exceeding 2 ml kg 1 h 1 measured between arrival in the intensive care unit (ICU) and the earliest of the elapse of 3 h; the start of transfusion of any one of fresh-frozen plasma, platelets or cryoprecipitate; return to theatre or death. Univariate and multivariate associations of severe postoperative bleeding with patient characteristics, clinical features and procedure details were analysed on a development set. The final risk stratification scheme was then evaluated on a test set. Results: Severe postoperative bleeding was associated with urgent or emergency surgery, surgery that was not coronary artery bypass grafting or single valve surgery, presence of aortic valve disease, low body mass index and older age. A risk stratification score was constructed from the above variables to define preoperative categories that demonstrated high, medium and low risk of severe postoperative bleeding. Patientsdeemed to beathigh, mediumand lowrisk byourpreoperativescoringhada 21% (95%confidenceinterval: 18—24%),8%(7—10%) and 3% (2—4%) rate of severe postoperative bleeding, respectively, within the test set. Conclusion: We have developed a simple risk stratification score that can separate, preoperatively, patients into risk groups with markedly different rates of severe postoperative bleeding. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: This study suggests that re-exploration for bleeding after cardiac surgery carries a significantly increased risk of postoperative mortality and morbidity.
Abstract: OBJECTIVE: The aim of this study was to evaluate the impact of re-exploration for bleeding after cardiac surgery on the immediate postoperative outcome. METHODS: Systematic review of the literature and meta-analysis of data on re-exploration for bleeding after adult cardiac surgery were performed. RESULTS: The literature search yielded eight observational studies reporting on 557 923 patients and were included in the present analysis. Patients requiring re-exploration were significantly older, more frequently males, had a higher prevalence of peripheral vascular disease and preoperative exposure to aspirin, and more frequently underwent urgent/emergency surgery. Re-exploration was associated with significantly increased risk ratio (RR) of immediate postoperative mortality (RR 3.27, 95% confidence interval (CI) 2.44–4.37), stroke, need of intra-aortic balloon pump, acute renal failure, sternal wound infection, and prolonged mechanical ventilation. The pooled analysis of four studies (two being propensity score-matched pairs analysis) reporting adjusted risk for mortality led to an RR of 2.56 (95%CI 1.46–4.50). Studies published during the last decade tended to report a higher risk of re-exploration-related mortality (RR 4.30, 95%CI 3.09–5.97) than those published in the 1990s (RR 2.75, 95%CI 2.06–3.66). CONCLUSIONS: This study suggests that re-exploration for bleeding after cardiac surgery carries a significantly increased risk of postoperative mortality and morbidity.
TL;DR: Since self-perception is a major contributor to therapeutic decision making, a systematic evaluation of body image should be included in the assessment of patients with chest deformities, and body image concerns may be even more relevant to the decision-making process than physical restrictions.
Abstract: Objective: The aim of this study was to evaluate the effects of anterior chest-wall deformities on disease-specific and health-related quality of life, body image, and psychiatric comorbidity prior to surgical correction. Methods: A total of 90 patients (71 with pectus excavatum, 19 with pectus carinatum) presenting themselves for pectus repair and 82 control subjects were recruited for this study. The objective severity of the deformity was determined through the funnel-chest index by Hummer and the Haller index. Disease-specific quality of life was measured with the Nuss Questionnaire modified for Adults (NQ-mA) and health-related quality of life was determined by the Short-Form-36 Health Survey (SF-36). Body image was assessed via the Body Image Questionnaire (FKB-20), the Dysmorphic Concern Questionnaire (DCQ), and a self-evaluation of the subjective impairment of the appearance. The Diagnostic Interview for Mental Disorders — Short Version (Mini-DIPS), the General Depression Scale (Allgemeine Depressionsskala, ADS), and a self-rating of self-esteem were used to evaluate general psychological impairment. Results: Compared with control group results, physical quality of life was reduced in patients with pectus excavatum, while mental quality of life was decreased in patients with pectus carinatum ( p < 0.05). Body image was highly disturbed in all the patients and differed significantly from the control group ( p < 0.01). Patients with pectus carinatum appeared to be less satisfied with their appearance than those with pectus excavatum ( p = 0.07). Body image distress was multivariately associated with both reduced mental quality of life and low self-esteem ( p < 0.001). Body image did not influence physical quality of life. Patients displayed no elevated rates of mental disorders according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. Conclusion: Since self-perception is a major contributor to therapeutic decision making, a systematic evaluation of body image should be included in the assessment of patients with chest deformities. Body image concerns may be even more relevant to the decision-making process than physical restrictions. Exaggerated dysmorphic concerns should be prospectively investigated in their ability to influence the extent of satisfaction with the surgical outcome. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: A standardized set of definitions and nomenclature were proposed to set a scientifically based framework with which to evaluate existing studies and to more clearly formulate questions, parameters, and outcomes for future studies.
Abstract: The present project involved a collective effort agreed by the European Society of Thoracic Surgeons, the American Association for Thoracic Surgery, the Societyof ThoracicSurgeons,and the General Thoracic SurgeryClub to assemble a joint panel of expertsto review the available data and address ambiguous aspects of chest tube definitions and nomenclature. The task force was composed of 11 invited participants, identified for their expertise in the area of chest tube management. The subject was divided in different topics, which were in turn assigned to at least two experts. The draft reports written by the experts on each topic were distributed to the entire expert panel, and comments solicited in advance of the meetings. During the meetings, the drafts were reviewed, discussed, and agreed on by the entire panel. Standardized definitions and nomenclature were proposed for the following topics related to chest tube management: pleural and respiratory mechanics after pulmonary resection; external suction versus no external suction; fixed versus variable suction; objective air leak evaluation; objective fluid drainage evaluation; and chest drain: type, number, and size. A standardized set of definitions and nomenclature were proposed to set a scientifically based framework with which to evaluate existing studies and to more clearly formulate questions, parameters, and outcomes for future studies. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: The results strongly support the need for intra-operative tools to reduce contrast-agent exposition during TA-AVI and support the postoperative renal outcome, an improved or at least stable eGFR was seen in more than 50% of the patients.
Abstract: Objective: Contrast agent is a potential risk factor for acute kidney injury (AKI). Little is known about the incidence of contrast-induced nephropathy (CIN) after trans-apical aortic valve implantation (TA-AVI) and on the impact of contrast exposure during preoperative computed tomography (CT) scan and cardiac catheterization. Methods:A total of 270 consecutive high-risk patients received TA-AVI for symptomatic aortic valve stenosis during a 3-year period. Different preoperative, peri-procedural, and postoperative variables were analyzed by uni- and multivariate logistic regression concerning incidence of early ( 99 ml (OR = 2.3, p = 0.038), new thrombocytopenia (OR = 4.4, p = 0.005) and pathological leucocyte count (OR = 2.8, p = 0.009) were independent risk factors for this event. Early (within 1—7 days before TA-AVI) preoperative CT and cardiac catheterization did not significantly increase incidence of RRTor AKI. Short-term and long-term survival was explicitly lower in the AKI and in the RRT groups (p < 0.001 each).Conclusions:GFR improvesafter TA-AVI. Postoperative AKI and RRT depend on the amount of intra-operative contrast agent.These results strongly support the need for intra-operative tools to reduce contrast-agent exposition during TA-AVI. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: Aged human aortic tissues were significantly stiffer than the corresponding porcine tissues in both the circumferential and longitudinal directions, which raises questions on the validity of using porCine models to investigate the biomechanics involved in PAV intervention.
Abstract: Objective:Currently,percutaneousaorticvalve(PAV)replacementdevicesarebeinginvestigatedtotreataorticstenosisinpatientsdeemedto be of too high a risk for conventional open-chest surgery. Successful PAV deployment and function are heavily reliant on the tissue—stent interaction. Many PAV feasibility trials have been conducted with porcine models under the assumption that these tissues are similar to human; however, this assumption may not be valid. The goal of this study was to characterize and compare the biomechanical properties of aged human and porcine aortic tissues. Methods: The biaxial mechanical properties of the left coronary sinus, right coronary sinus, non-coronary sinus, and ascending aorta of eight aged human (90.1 � 6.8 years) and 10 porcine (6—9 months) hearts were quantified. Tissue structure was analyzed via histological techniques. Results: Aged human aortic tissues were significantly stiffer than the corresponding porcine tissues in both the circumferential and longitudinal directions (p < 0.001). In addition, the nearly linear stress—strain behavior of the porcine tissues, compared with the highly nonlinear response of the human tissues at a low strain range, suggested structural differences between the aortic tissues from these two species. Histological analysis revealed that porcine samples were composed of more elastin and less collagen fibers than the respective human samples. Conclusions: Significant material and structural differences were observed between the human and porcine tissues, which raise questions on the validity of using porcine models to investigate the biomechanics involved in PAV intervention. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: Emergency surgery for septuagenarians with acute aortic dissection type A (AADA) resulted in acceptable mortality, andOctogenarians revealed significantly higher 30-day mortality, although it was lower than the mortality among patients without surgical treatment.
Abstract: Objective: The number of elderly patients undergoing emergency surgery for acute aortic dissection type A (AADA) is rising. Published results report a higher risk for thesepatients comparedwith younger patients. The aim of our study wasto analyse the surgicaloutcomeof these patients and to identify those at risk. Methods: Between July 2006 and June 2009, 44 centres participating in the German Registry for Acute Aortic Dissection Type A (GERAADA) reported a total of 1558 patients. As many as 381 patients were between 70 and 80 years of age (septuagenarians), while 83 patients were 80 years and older (octogenarians). We compared the clinical features and events occurring 30 days after surgery.Results: Onadmission,23%(n = 89)ofseptuagenarianshadcardiactamponade,comparedwith31%(n = 26)ofthoseage80years(p = 0.13).Alittlemore than 13% (n = 48) of septuagenarians were intubated at admission compared with 21% (n = 17) of octogenarians (p = 0.06). The septuagenarians’ 30-daypostoperativemortalitywas16%(n = 60),whereasthatofpatientsagedover80 yearswas35%(n = 29)(p < 0.001).Themeanhospitalstay in the younger group was 18 days, of which 12 days were in the intensive care unit, compared with 18 and 13 days for octogenarians, respectively. Conclusions: Emergency surgery for septuagenarians with acute aortic dissection type A (AADA) resulted in acceptable mortality. Octogenarians revealed significantly higher 30-day mortality (odds ratio (OR) = 3.23, confidence interval (CI) = (1.81—5.72)), although it was lower than the mortality among patients without surgical treatment. A surgical approach should be considered in all patients on an individual basis. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: Ccinoids are rare malignant tumors and are, in most cases, resectable; the TC subgroup had better prognosis than the AC in univariate analyses.
Abstract: Objective: Few published reports have examined the incidence and outcomes for patients with carcinoid lung tumors. The aim of the current study was to explore incidence, type of surgical treatment given, and outcome for patients with typical (TC) and atypical (AC) lung carcinoids in a national cohort (Norway).Methods: All lung-cancer patients diagnosed in the period 1993—2005 and who were reported to the Cancer Registry of Norway were identified. Biopsies or resection specimens were reviewed and reclassified according to the World Health Organization (WHO) 2004 classification. Surgically treated patients were staged according to the seventh edition of the pathological tumor—node—metastasis (pTNM) staging system. Results: Of 26 665 lung cancers registered during the period, 265 (1%) had carcinoid tumors, of which 11 were diagnosed coincidentally at autopsy. In the remaining 254 patients, TCs were found in 188 cases, and ACs were found in 59 cases; seven cases had unclassifiable carcinoids. Of the 217 resected tumors, 173 (80%) were TCs. General surgeons performed 94 resections, including 11 of 17 pneumonectomies. All six bronchial resections were performed by thoracic surgeons. Of the 33 operated patients who died during follow-up, 18 had metastatic carcinoid tumors, of which 10 (56%) were ACs. In 37 non-resected patients (15 with AC and seven with unclassifiable histology), metastatic or locally advanced disease (N = 21, 12 of which were ACs) was the main cause of inoperability and death. Five-year survival for all patients was 92% for TC and 66% for AC; for resected patients, the survival rates were 96% and 79%, respectively. Conclusions:Carcinoids are rare malignant tumors and are, in most cases, resectable; the TC subgroup had better prognosis than the AC in univariate analyses. The main cause of death was metastasis/locally advanced tumor at presentation or recurrent disease following resection; both situations were three times more common in patients with AC. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: Regardless of the underlying pathology, valve-sparing David I procedure has acceptable long-term results and Valve-related complications such as stroke or major bleeding is exceedingly low.
Abstract: OBJECTIVE
Aortic valve-sparing David procedure has gained broad acceptance. However, few long-term results have been published. We present our results.
TL;DR: Occurrence of PGF is a multifactorial event that depends on both donor and recipient profiles; furthermore, surviving patients treated with ECMO have the same 1-year conditional survival rates as patients not having suffered a PGF.
Abstract: Objective:Primarygraftfailure(PGF)isa majorriskfactorfordeathafterhearttransplantation.Weinvestigatedthepredictiveriskfactorsfor severe PGF that require extra-corporeal membrane oxygenation (ECMO) circulatory support after cardiac transplantation. Methods: Between January 2003 and December 2008, 402 adult patients underwent isolated cardiac transplantation at our institution. PGF was defined as the need for ECMO support in the immediate postoperative period. Thirty-three recipient and 37 donor variables were analyzed for the risk of PGF occurrence. Results: PGF occurred in 91 (23%) patients. Predictive risk factors for PGF occurrence were, in the recipient, being aged >60 years (odds ratio (OR) 2.11, p = 0.01) and preoperative mechanical circulatory support (MCS) (OR 2.65, p = 0.01); in the donor, they were mean norepinephrine dose (OR 2.02,p < 0.01), trauma as the cause of death(OR 2.45,p < 0.01), left-ventricle ejection fraction (LVEF) <55% (OR 2.72, p = 0.02), and the ischemic time (OR 1.01, p < 0.01). Weaning and discharge rates after ECMO support for PGF were, respectively, 60% (55/91 patients) and 46% (42/91 patients).The absence of PGF was correlated with improved long-termsurvival: 78% at 1 year and 71% at 5 years without PGF versus 39% at 1 year and 34% at 5 years with PGF (p < 0.01). Surviving patients treated with ECMO for PGF have similar conditional 1-year survival rates as non-PGF patients: 93% at 3 years and 91% at 5 years without PGF versus 93% at 3 years and 84% at 5 years with PGF (p = 0.46, NS). Conclusions: Occurrence of PGF is a multifactorial event that depends on both donor and recipient profiles. ECMO support is a reliable treatment for severe PGF;furthermore,survivingpatients treated with ECMO have the same 1-year conditional survival ratesas patients not havingsuffered a PGF. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: Data acquired over 30 years confirm that women with prosthetic heart valves, especially aortic prostheses for congenital lesions, generally tolerate pregnancy well, although cardiac mortality, mortality related to anticoagulation and thrombo-embolic risks are raised.
Abstract: Objective: Pregnancy in women with prosthetic heart valves remains a risk factor for both mother and fetus, but unselected and unbiased outcome and complication data remain scarce. We analyzed nationwide outcome data from 1977 to 2007 for all pregnancies in women with prosthetic valves. Methods: Cardiac, obstetric, and neonatal data were obtained from obligatory databases and compared with general female population data. Questionnaires were used to corroborate important information. Outcome data were analyzed according to type of anticoagulation used. The data were compared between the two first and the last decades of the study period. In the last decade, patients were comparedtoan age-adjustedselectedpopulationofhealthy, pregnantwomen.Results:Of356womenbetween15and40yearsofage,79 women had 155 pregnancies after valve replacement. Two women died during pregnancy, one from heart failure and one from post-partum bleeding. There were four thrombo-embolic episodes in the early study period in women with mitral prosthesis on unfractionated heparin. Important cardiac complications were otherwise almost absent. There were significantly more early miscarriages and terminations in patients compared with controls (last decade 34%, vs 20% (p = 0.0036) and 26% vs 13% (p = 0.000019)). Post-partum bleeding was more common in the patient group (p = 0.0021). Two late fetal losses (one from intracerebral bleeding) were seen. The remaining pregnancies resulted in 60 live births. Cesarean sectionwasthe predominant methodof deliveryinpatientsas opposedto controls(55%vs16%,p = 0.000000000097).Prematurebirthsweremore frequent in patients (49% vs 5.5%, p = 0.00000000039) as were congenital malformations (14% vs 5.7%, p = 0.044). Two of the six malformations were warfarin embryopathy (8% of all first-trimester warfarin exposures), both seen in high-risk patients on high warfarin dosing. Small for gestational age did not differ significantly from the general population (9.3% vs 6.0%, p = 0.39). Conclusion: Data acquired over 30 years confirm that women with prosthetic heart valves, especially aortic prostheses for congenital lesions, generally tolerate pregnancy well, although cardiac mortality, mortality related to anticoagulation and thrombo-embolic risks are raised. Our data provide further documentation on the significance and importance of the risks associated with predominantly warfarin-based treatment regimens, which still remains optional for a number of patients. Finally, the data also serve as a comparison for recently published series based on low-molecular-weight heparin (LMWH) regimens. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: It is concluded that, over the past three to four decades, achieving the goal of a prosthetic graft with equivalent function and durability to the internal mammary artery or long saphenous vein has proved to be elusive.
Abstract: Prosthetic grafts are required for coronary artery bypass grafting (CABG) when the availability of suitable autologous conduits is limited. The ideal cardiovascular bypass graft requires a broad range of characteristics including strength, viscoelasticity, biocompatibility, blood compatibility and biostability. Many alternative conduits have been developed and used in the past, but most of them have failed, except in rare instances. This review aims to analyse the current status of their use and prospects for the future. We performed a literature search on PubMed using the generic terms 'conduits for coronary artery bypass grafting'; 'reoperative coronary artery bypass grafting'; 'redo coronary artery bypass grafting'; 'PTFE'; 'Dacron or PET'; 'gastroepiploic artery'; 'inferior epigastric artery'; 'biological grafts'; 'tissue-engineered grafts'; 'synthetic grafts'; 'prosthetic grafts'; 'polyurethane grafts'; 'cephalic veins'; 'short saphenous vein;' and 'alternative conduits'. In addition, we searched through related citations and references from selected articles. A total of 1253 references and 110 full-text articles were reviewed, and they were further selected based on available information. This review concludes that, over the past three to four decades, achieving the goal of a prosthetic graft with equivalent function and durability to the internal mammary artery or long saphenous vein has proved to be elusive.
TL;DR: ECMO can be a first-line tool to rescue this group of patients with high mortality rates in spite of advanced mechanical support, due to its simplicity and effectiveness.
Abstract: Objectives: Acute fulminant myocarditis (AFM) is a disease category that is easily neglected. Circulatory mechanical support is sometimes required for this devastating condition. We analyzed our experience in managing AFM with mechanical circulatory support. Methods: We applied extracorporeal membrane oxygenation (ECMO) as a first-line rescue for AFM. The diagnosis was mainly derived from clinical results and biopsy. Results: Seventy-five patients were enrolled in the age range of 29.6 18.6 years and the pediatric group (<18 years) comprised 32% (n = 24) of our patientgroup. Thirty-fivepatients (47%) underwentcardiopulmonary resuscitation (CPR) beforeECMO.The indicationfor ECMO includedhigh inotropic support 69% (n = 54) and continuous CPR at ECMO setup 31% (n = 23). The ECMO duration was 171 121 h. Survival to discharge was 64% (n = 48), 61% in adult group, and 70.8% in pediatric group. Six patients were later bridged to ventricular assist device use (5 left ventricular assist device (LVAD) and 1 bi-ventricular assist device (BVAD)) but three died of multiple-organ failure. Three patients (4%) underwent heart transplantation and all of them survived to discharge. Resuscitation did not have a significant factor for survival. Only two patients (3%) developedlate mortality due to a cardiac event.Conclusions:AFM still carries high mortalityrates in spite of advanced mechanical support.Most of the survivors did not require transplantation and could return to good lifestyle. Due to its simplicity and effectiveness, ECMO can be a first-line tool to rescue this group of patients. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: MICS CABG is a valuable alternative for patients in need of multivessel CABGs and appears at least as safe as OPCAB, and associated with shorter hospital length of stay, less wound infections, and faster postoperative recovery than O PCAB.
Abstract: Objective: The minimally invasive coronary artery bypass grafting (MICS CABG) operation performed via a small thoracotomy has not previously been examined in a direct comparison to sternotomy off-pump coronary artery bypass grafting (OPCAB). Methods: We matched, according to age, gender,leftventricularfunction,andmediannumberofdistalanastomoses,150patientswhounderwentMICSCABGviasmallleftthoracotomy,and 150patientswhoreceivedsternotomyOPCAB.Alloperationswereperformedbythesamesurgeon.Results:Therewasnoperioperativemortality(0/ 300).IntheMICSCABGgroup,pumpassistancewasusedin28/150(19%)patients,andconversiontosternotomyoccurredin10/150(6.7%)patients.In the OPCAB group, conversion to on-pump occurred in 3/150 (2.0%) patients. There were four (2.7%) reoperations for bleeding and one (0.7%) for anastomotic revision in each group. The median hospital length of stay was 5 days for MICS CABG (average 5.4), and 6 days for OPCAB (average 7.2) (P = 0.02). New-onset atrial fibrillation occurred in 35 (23%) MICS CABG patients and in 42 (28%) OPCAB patients (P = 0.3). No wound infection occurredwithMICSCABGversussix(4.0%)withOPCAB(P = 0.03).Aself-limitingleftpleuraleffusiondevelopedin22(15%)MICSCABGpatientsandin six(4.0%)OPCABpatients(P = 0.002).Themediantimetoreturntofullphysicalactivitywas12daysinMICSCABGpatientsversus >5weeksinOPCAB patients (P < 0.001). Conclusions: MICS CABG is a valuable alternative for patients in need of multivessel CABG. The operation appears at least as safe as OPCAB, and associated with shorter hospital length of stay, less wound infections, and faster postoperative recovery than OPCAB. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: A number of factors correlated with persistent thoracic pain following cardiac surgery with sternotomy are identified, thereby potentially ameliorating the postoperative quality of life of a significant proportion of patients.
Abstract: Objective: This study examines the influence of patient demographics and peri- and postoperative ( 0) associated with the primary surgery. Results: One year after surgery, 42 (35%) of the 120 responding patients reported chronic thoracic pain. Multivariate regression analysis of patient characteristics revealed that nonelective surgery, re-sternotomy, severe pain (numeric rating scale 4) on the third postoperative day, and female gender were all independent predictors of chronic thoracic pain. In addition, the chronic sufferers reported more sleep disturbances and more frequent use of analgesics than their cohorts. Conclusions: We have identified a number of factors correlated with persistent thoracic pain following cardiac surgery with sternotomy. Awareness of these predictors may be useful for further research concerning both the prevention and treatment of chronic thoracic pain, thereby potentially ameliorating the postoperative quality of life of a significant proportion of patients. Meanwhile, chronic thoracic pain should be discussed preoperatively with patients at risk so that they are truly informed about possible consequences of the surgery. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: This small pilot study shows that BD stents are a safe, effective and reliable alternative to classical metallic stents in patients with anastomotic stenosis after lung transplantation, and may avoid the need for permanent stenting.
Abstract: Objective:To evaluate the safety and effectiveness of novel biodegradable (BD)stents to treatbronchial anastomotic stenosisin patients after lung transplantation. Methods: Twenty BD stents were implanted endoscopically in six patients (median age 41.5 years (range 35—57 years)) with post-transplant bronchialanastomoticstenoses, between2006and 2010.All stentswerecustom-madefrombio-absorbablepolydioxanone (PDS). The median stent diameter was 12 mm (8—17 mm) and median length was 20 mm (12—30 mm). All patients were evaluated clinically, by bronchoscopy and high-definition computed tomography (CT). Results: The stenosis was initially relieved in all cases. There was no bleeding, perforation or displacement after BD stent implantation. Four patients needed multiple stenting for anastomotic re-stenosis. Median time to any re-stenting was 5 months (2—15 months). There was one sudden death, 1 year after the last BD stent implantation, from a pulmonary embolus. All five survivors are in good clinical condition up to 4 years’ follow-up (median 40 months, range 7—48 months) since first stenting and interventionfree up to 44 months (median 24 months, range 7—44 months). Conclusions: This small pilot study shows that BD stents are a safe, effective and reliable alternative to classical metallic stents in patients with anastomotic stenosis after lung transplantation, and may avoid the need for permanent stenting. Crown Copyright # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: As more experience is gained over time, with more cases performed each year and less invasive approaches, results improve in terms of less surgical time and more extended lymphadenectomies.
Abstract: Objective: To analyse the evolution of the video-assisted thoracoscopic (VATS) approach for lobectomy and results during the first 3 years of program.Methods: From 1 st July-2007 to 31 th July-2010 we carried out 200 lobectomies by VATS. In February 2009 we started performing VATS lobectomies with only 2 incisions .We have analyzed both annual and overall outcomes regarding type of approach, conversion rate, surgical time, lymphadenectomy and overall survival. Results: Distribution of the cases per year were as follows: first-year 32, second-year 65, thirdyear 103. Overall conversion rate was 14,5% (first-year 25%, second-year 20%, third-year 7.8%; p = 0.017). Surgical approach was: 4 ports (1 case), 3 ports (99 cases, 100% in first-year), 2 ports (99 cases, 80% in third-year), single-port (1 case, third-year) Mean surgical time in successful VATS was 193.8 min (210.8 first-year, 207.9 second-year, 181.1 third-year; p = 0.011), mean number of lymph nodes were 11.9 (9.3 first-year, 10.1 second-year, 13.9 third-year; p = 0.003) and mean explored stations was 4.2 (3.6 first-year, 3.8 second-year, 4.5 third-year; p < 0.001). Globally median chest tube duration was 3 days. Median length of stay was 4 days. The disease-free survival at 30 months was 85% for Stage I patients and 62% for non-stage I patients. Conclusions: As we gain more experience over time, with more cases performed each year and less invasive approaches, results improve in terms of less surgical time and more extended lymphadenectomies. Furthermore, we have observed a clear evolution in our surgical approach to a less invasive 2-port approach. In selected cases we have implemented the singleport lobectomy # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
TL;DR: It is indicated that high-dose TXA is associated with an increased incidence of postoperative generalized seizures in patients undergoing AVR compared with EACA, especially when suffering from renal impairment.
Abstract: To investigate the incidence of postoperative generalized seizures in patients undergoing aortic valve replacement (AVR) under extracorporeal circulation, who received either high-dose tranexamic acid (TXA) or epsilon aminocaproic acid (EACA) as an antifibrinolytic agent. Methods: This retrospective analysis comprised 682 consecutive patients undergoing AVR with or without simultaneous coronary artery bypass surgery. Patients operated on before March 2008 were treated intra-operatively with TXA (100 mg kg(-1); n = 341), patients operated on after March 2008 received EACA (50 mg kg(-1) loading dose, followed by 25 mg kg(-1) h(-1), and an additional 5 g in the extracorporeal circuit; n = 341). Results: Clinically diagnosed generalized seizures were observed within the first 24 h postoperatively, more frequently in patients receiving TXA compared with EACA (6.4% vs 0.6%, p < 0.001, difference = 5.8%, 95% confidence interval 3.1-8.5%). Besides the antifibrinolytic agent, three other variables differed significantly between patients with and without postoperative seizures: age (mean (SD), 77.0 (5.9) years vs 73.2 (9.0) years, p = 0.039), preoperative creatinine clearance (55.4 (16.5) ml min(-1) vs 72.6 (28.5) ml min(-1), p = 0.002), and administration of recombinant activated factor VIIa (3 out of 24 patients (12.5%) vs 8 out of 658 patients (1.2%), p = 0.005). Logistic regression analysis demonstrated a significant impact of the antifibrinolytic drug, creatinine clearance, and the application of recombinant activated factor VIIa on the occurrence of generalized seizures. Conclusions: Our results indicate that high-dose TXA is associated with an increased incidence of postoperative generalized seizures in patients undergoing AVR compared with EACA, especially when suffering from renal impairment. A possible association between recombinant activated factor VIIa and the occurrence of postoperative seizures needs further investigation. (C) 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.