Aleksandar Mikic

Surgical revascularization on the beating heart in patients with low ejection fraction

INTRODUCTION The subset of patients most likely to benefit from off-pump coronary artery bypass grafting (OPCABG) remains a controversial issue, but the technique has been proposed to decrease postoperative mortality and morbidity. Coronary artery bypass grafting (CABG) with a cardiopulmonary bypass carries a significant risk for patients with severe left ventricular (LV) dysfunction. OBJECTIVE The objective of this study was to compare off-pump to on-pump CABG in patients with ejection fraction (EF) lower than 30%. METHODS Prospective randomized study was carried out between June 2004 and March 2006 at the Institute for Cardiovascular Diseases of the Clinical Centre of Serbia. Sixty prospectively randomized high-risk patients divided into two groups to undergo off-pump or on-pump CABG. All recruited patients had left ventricular ejection fraction lower than 30%. RESULTS Thirty patients averaging 59.2 years of age underwent 2.30 grafts on pump, and another 30 averaging 59.6 years of age underwent 2.03 grafts off pump. OPCABG patients exhibited a significantly less release of TnI (average 0.71 micro/L) than on-pump patients (3.00 micro/L). Inotropic requirements were less in the off-pump group. The patients undergoing OPCABG received fewer units of blood and had shorter postoperative length of stay in intensive care unit and hospital stay. There was no significant difference in hospital mortality and complication rate. CONCLUSION The present study suggests that off-pump CABG in patients with poor LV function when compared with conventional CABG achieved similar number of grafts per patient, similar in-hospital outcomes, shorter length of stay, reduced transfusion requirement, and less myocardial injury.

Postoperative Bleeding Following Preoperative Clopidogrel Administration in Patients with Haemoglobin Level Above 110 g/L Undergoing Urgent CABG

Introduction Patients with acute coronary syndrome usually receive dual antiplatelet therapy (DAPT) (usually clopidogrel + aspirin) prior to coronary catheterization, and approximately 10% of these patients require coronary artery bypass grafting (CABG). DAPT has favorable effects on prevention of thrombus formation, but it can have deleterious effects on surgical hemostasis. Anaemia, if present, gives additional risk to such patients. The aim of this study was to examine if DAPT affects postoperative bleeding in patients with haemoglobin levels above 110 g/L, who underwent urgent or emergent CABG, less than five days after stopping DAPT therapy. Methods Data were collected prospectively on 122 CABG patients, operated by a surgical team from March 2008 to August 2013. Patients were stratified into two groups: group 1 received DAPT within 5 days of CABG (n=65), and group 2 where DAPT was discontinued for more than 5 days prior to CABG (n=57). All patients were diagnosed with acute coronary syndrome preoperatively, and all of them had haemoglobin levels above 110 g/L. Patients who needed reoperation, combined procedures, or off-pump revascularization were excluded. Results There was no hospital mortality. Mean chest tube losses after the surgical revascularization did not differ significantly, but group 1 received a higher quantity of transfused red blood cells and platelets. Conclusion Urgent and emergent surgical revascularization using extracorporeal circulation in patients with acute coronary syndrome whose preoperative haemoglobin levels are above 110 g/L is a safe and effective procedure. We suggest that, where indicative, one may perform CABG in less than 5 days after the clopidogrel discontinuation.

Surgery for the acute dissections of the ascending aorta and the arch

Overall early mortality was 23.3% (53 pts): operative 7.5% (17 pts) and hospital 15.9% (36 pts). The early major postoperative complications were: low cardiac output syndrome 28 pts (12.3%), hemorrhage 24 pts (10.5%), focal neurological deficit 26 pts (11.4%), coma 16 pts (7.0%) and acute renal failure 12 pts (5.3%). Conclusions During this period of time, we have adopted a strategy of “the earliest possible surgery”, reducing preoperative diagnostic algorithm on carefully clinical examination and the least possible number of imaging tools. The more successful tactics of aortic dissection treatment should focus on: earlier clinical suspicion and diagnosis decrease in “onsetto-admission” time, improvements in surgical strategy/ technique and establishment of National aortic dissection registry.

Minithoracotomy as a primary alternative for LV lead implantation during coronary resynchronization therapy

Background Numerous anomalies of cardiac venous system prevent optimal endovascular implantation of LV lead in more than 15% of patients with heart failure and indications for Coronary Resynchronization Therapy (CRT). Insisting on endovenous approach in these patients can be one of the potentional reasons for large number of nonresponders reported in the literature. Purpose of this study was to analyze the results of an alternative mioepicardial approach to the stimulation of the left ventricle in CRT.

Our experience in three coronary patients with heparin induced thrombocytopenia type II, platelets

Background Heparin induced thrombocytopenia type II (HIT type II) is well defined thrombophylic and immunological complication due to heparin therapy, Witch occurs in 1-3% treated patients. In around 50% of the patients with HIT type II have developed serious thrombotic arterial and venous complications. It has a special place in cardiac surgery, regarding standard use of heparin. In patients with HIT type II is contraindicated continuation of heparin therapy including use of low molecular heparin. Alternative drugs should be used as danaparoid sodium, lepirudin , argatroban.