Alexander Kogan

Modified thromboelastography evaluation of platelet dysfunction in patients undergoing coronary artery surgery.

OBJECTIVEnAnti-platelet therapy is associated with increased perioperative bleeding. Although current guidelines call for its caessation 5-10 days prior to cardiac surgery, this could constitute an increased risk of preoperative myocardial infarction. The optimal safe period from discontinuation of anti-platelet therapy to surgery is as yet unknown for the individual patient. We investigated whether preoperative thromboelastography (TEG) with platelet mapping could predict bleeding tendency in patients (on recent anti-platelet therapy) undergoing coronary artery bypass grafting (CABG).nnnMETHODSnWe prospectively evaluated 59 patients on aspirin and clopidogrel therapy who underwent CABG. Of them, 25 patients received aspirin alone. TEG with platelet mapping was performed immediately prior to surgery in all 59 patients.nnnRESULTSnDuring the first 24h post-surgery, 9/59 patients bled excessively (1216 + or - 310 ml in excessive bleeding vs 576 + or - 155 ml in non-bleeding patients). Of the patients bled excessively, eight received clopidogrel treatment prior to surgery. However, 26 of the remaining 34 patients receiving clopidogrel did not bleed significantly. Clopidogrel-induced platelet dysfunction diagnosed by platelet mapping discerned between patients who demonstrated excessive bleeding and those who did not (78% - sensitivity, 84% - specificity, p=0.004). Aspirin-induced platelet dysfunction did not reflect a bleeding tendency. Of all patients, 85% did not respond to a standard dose of clopidogrel, whereas 44% did not respond to aspirin.nnnCONCLUSIONSnTEG with platelet mapping is able to predict excessive postoperative blood loss among patients who underwent CABG and recent anti-platelet therapy. The prevalence of non-responsiveness to anti-platelet therapy, including clopidogrel, is higher in patients undergoing coronary artery bypass grafting than in the general population. In this study, aspirin-induced platelet dysfunction did not influence postoperative blood loss.

Course and outcome of obstetric patients in a general intensive care unit

Background. To characterize the course, interventions required to achieve predetermined end‐points and outcome of obstetric patients admitted to a general intensive care unit.

The impact of hyperlactatemia on postoperative outcome after adult cardiac surgery

PurposeTo evaluate the value of blood lactate value in predicting postoperative mortality (primary outcome), duration of ventilation, and length of stay in an intensive care unit (ICU) and hospital (secondary outcomes).MethodsWe performed a prospective observation study on 1,820 consecutive patients undergoing open heart surgery in a tertiary university medical center. Blood lactate levels were obtained from patients on admission to the cardiac surgical ICU and measured serially.ResultsAll patients were divided into three groups according to their maximum blood lactate levels: group I (normolactatemia, lactate ≤2.2xa0mmol/l), 332 patients; group II (mild hyperlactatemia, lactate 2.2–4.1xa0mmol/l), 1,054 patients; and group III (severe hyperlactatemia, lactate ≥4.4xa0mmol/l), 434 patients. Maximum blood lactate levels ≥4.4xa0mmol/l during the first 10xa0h post admission were associated with prolonged ventilation time, longer ICU stay, and increased mortality (Pxa0<xa00.001).ConclusionsHyperlactatemia is common after cardiac surgery. Maximal lactate threshold ≥4.4xa0mmol/l in the first 10xa0h after operation accurately predicts postoperative mortality.

Takotsubo Syndrome After Cardiac Surgery

We have not found any reports to date of Takotsubo syndrome after cardiac surgery. Recently described Takotsubo syndrome is characterized by acute reversible left ventricular dysfunction with apical ballooning in the absence of coronary artery disease, and with chest pain and electrocardiographic changes mimicking acute anterior myocardial infarction, but with minimal release of myocardial enzymes. We describe Takotsubo syndrome that developed after elective mitral valve replacement and tricuspid annuloplasty in a 62-year-old woman. On supportive therapy with vasopressors, left ventricular function gradually improved with an ejection fraction returning to 50%. Takotsubo cardiomyopathy should be considered as a possible complication of the cardiac surgery.

Cardiac surgery in patients on chronic hemodialysis: short and long-term survival.

OBJECTIVEnOpen-heart surgery carries a high risk for hemodialysis patients. This study focuses on the short and long-term outcomes of hemodialysis patients undergoing heart surgery.nnnDESIGNnThe study was carried out as a retrospective analysis in the Department of Cardiothoracic Surgery in a large university-affiliated hospital.nnnPATIENTSn115 hemodialysis patients underwent cardiac surgery in our department between 1 July 1996 and 31 July 2006. 67.5 % (77 patients) underwent isolated coronary artery bypass grafting (CABG), 13.2 % (15 patients) underwent isolated aortic valve replacement (AVR) and 20.2 % (23 patients) underwent mitral valve surgery or combined valve and coronary artery bypass grafting or multiple valve surgery.nnnMETHODSnThe relationship between several variables (age, sex, hypertension, diabetes, and previous myocardial infarction, type of disease, preoperative ejection fraction, and congestive heart failure) and operative (30 days) mortality and late survival was analyzed.nnnRESULTSnThe overall 30-day mortality was 18.3 % (21 patients). It was 13 % (10/77 patients) for the isolated CABG group and 13.3 % (2/15) for the isolated AVR group. Patients undergoing combined valve and coronary surgery or multiple valve surgery had a higher perioperative mortality of 39.1 % (9/23) compared to the isolated CABG and isolated AVR patients. Perioperative death was also higher in patients with moderate and severe LV dysfunction, and in patients with diabetes. The duration of dialysis periods was not related to perioperative death. Mean follow-up was 26.4 +/- 29.7 months (0.1 to 104 months). Actuarial survival at 1 year and 5 years was 76 % and 55 % for isolated CABG, 59 % and 21 % for isolated AVR, and 44 % and 33 % for all other cases, respectively (log rank P = 0.001).nnnCONCLUSIONnPatients on dialysis have a high risk of perioperative mortality and poor long-term survival rates. Mortality is higher and survival is worse after combined CABG and valve-related procedures or multiple valve surgery than after isolated CABG and AVR.

Is gender an independent risk factor for coronary bypass grafting

BACKGROUNDnPostoperative mortality after coronary artery bypass grafting (CABG) surgery is traditionally considered to be influenced by gender. However, the data are conflicting and it is not clear whether gender is a true independent risk factor for death in this setting. We analyzed our database to determine whether gender is an independent risk factor for death after CABG.nnnPATIENTS AND DESIGNnA retrospective analysis of 1 758 isolated first-time coronary artery bypass graft patients treated between 2003 and 2005 was conducted in the Department of Cardiothoracic Surgery of Rabin Medical Center, a major tertiary facility in Israel.nnnRESULTSnThe female patients had a distinctly different pre- and intraoperative profile compared with the male patients, and significantly higher postoperative mortality (p < 0.05). On a propensity scoring of 359 matched pairs, the risk factors for death were found to be severe left ventricular dysfunction, chronic obstructive pulmonary disease, and use of an intra-aortic balloon pump (p < 0.05). The addition of intraoperative data to the model yielded only cardiopulmonary bypass time and use of an intra-aortic balloon pump as risk factors for death (p < 0.05). Validation with the bootstrap technique revealed that strong predictors of death (> 50 % of the sample) were cardiopulmonary bypass time, use of an intra-aortic balloon pump, and, to a lesser extent, chronic obstructive pulmonary disease. Female gender was not found to be an independent risk factor for death after coronary artery bypass graft.nnnCONCLUSIONSnFemale gender is apparently not an independent risk factor for coronary artery bypass graft mortality in this patient group.

Risk Factors for Failed “Fast-Tracking” After Cardiac Surgery in Patients Older Than 70 Years

OBJECTIVEnFast-track pathways have been successfully used in low-risk, relatively young patients after all types of surgical procedures including cardiac surgery. An increase in the number of referrals of older patients for cardiac surgery prompted the present study on the use of a fast-track pathway in septuagenarians and octogenarians. Risk factors for the unsuccessful application of the fast-track pathway in these elderly patients were determined.nnnDESIGNnA retrospective observational study.nnnSETTINGnA single tertiary-care, university-affiliated center.nnnPARTICIPANTSnAll 70-year-old or older patients undergoing cardiac surgery between January 1, 2004 and June 30, 2007 were included. Septuagenarians were compared with octogenarians.nnnMEASUREMENTS AND MAIN RESULTSnDuring the 42-month period, 860 cardiac operations were performed on 576 septuagenarians and 284 octogenarians. The fast-track pathway was successful in 54.5% and 37.3%, respectively. On multiple logistic regression analyses, stroke, renal failure, and procedures other than primary isolated coronary artery bypass graft surgery were independently associated with failed early extubation, delayed intensive care unit discharge, and delayed hospital discharge in both groups. Infections and atrial fibrillation were independent risk factors for delayed hospital discharge in both groups and delayed intensive care unit discharge in the octogenarians. In the octogenarians only, congestive heart failure was an independent risk factor for failed early extubation, delayed intensive care unit discharge, and delayed hospital discharge.nnnCONCLUSIONSnA fast-track pathway may be applied in selected septuagenarians and octogenarians. Age alone should not exclude consideration for fast-track management.

Late clinical outcome of transient intraoperative systolic anterior motion post mitral valve repair.

OBJECTIVEnSystolic anterior motion (SAM) after mitral valve repair with significant mitral regurgitation requires immediate reintervention. Transient SAM immediately after repair is usually managed by hemodynamic maneuvers. We investigated the late clinical and echocardiographic significance of postoperative transient SAM.nnnMETHODSnBetween 2004 and 2013, mitral valve repair was performed on 549 consecutive patients with degenerative mitral valve disease. Of the 45 patients (8.2%) identified with postrepair SAM, 5 needed immediate reintervention. Hemodynamic maneuvers, such as preload and afterload augmentation and rate control, effectively abolished SAM in 40 patients (SAM). They were followed and compared with the remaining 509 patients (non-SAM).nnnRESULTSnMean clinical follow-up was 54 ± 28 and 31 ± 26 months and was available in 100% and 95% (SAM and non-SAM) patients, respectively. One hospital death occurred in each group (P = .14). At follow-up, 2 patients (0.3%) showed significant SAM with left ventricular outflow tract obstruction, which resolved in 1 patient after beta-blocker therapy. SAM patients underwent exercise stress echocardiography: 1 patient showed left ventricular outflow tract obstruction that worsened after exercise. At 5 years, freedom from moderate or severe mitral regurgitation and New York Heart Association functional class III-IV was 85% versus 92% (P = .27) and 81% versus 92% (P = .15), and freedom from reoperation was 100% and 96% (P = .4), in SAM and non-SAM patients, respectively.nnnCONCLUSIONSnLate postoperative exercise stress echocardiogram revealed low incidence of SAM in patients with immediate postrepair transient SAM. All other late clinical outcomes were similar to those of non-SAM repair patients. Conservative management of intraoperative transient SAM is both successful and reliable.

Adult Respiratory Distress Syndrome Following Cardiac Surgery

Severe lung injury with the development of acute respiratory distress syndrome (ARDS) is a serious complication of cardiac surgery. The aim of this study was to determine the incidence, risk factors, and mortality of ARDS following cardiac surgery.

Midterm Results of Mitral Valve Repair: Closed Versus Open Annuloplasty Ring

BACKGROUNDnClosed and open annuloplasty rings are both used for mitral valve repair. This study compared the clinical and echocardiographic results in patients with degenerative mitral disease undergoing MV repair with closed semirigid rings vs open bands.nnnMETHODSnBetween 2004 and 2008, 377 patients (mean age, 59 + or - 12 years) underwent mitral valve repair. Valve pathology was degenerative in 273 (72%). Closed rings were used in 163 (60%) and open rings in 110 (40%). Patients had similar characteristics and comorbidities. In addition to annuloplasty, repair techniques included leaflet resection (48% and 77%, p < 0.01), artificial chordal (55% and 36%, p < 0.01), and edge-to-edge repair (4% and 4%, p = 0.79), in closed and open groups, respectively.nnnRESULTSnOne patient in each group died (0.7%). Mean follow-up was 19 + or - 14 (closed group) and 34 + or - 15 months (open group; p < 0.01). Freedom from reoperation was 97.5% (closed group) vs 96.5% (open group). At follow-up, New York Heart Association functional class was similar between groups, and 91% in the closed group and 84% in the open group were free from moderate or severe mitral regurgitation (p = 0.05). Closed group patients had a longer line of leaflet coaptation (9.1 + or - 2.7 mm) vs the open group (7.1 + or - 1.9 mm; p < 0.01).nnnCONCLUSIONSnPatients with closed semirigid annuloplasty rings demonstrated significantly longer lines of leaflet coaptation and tendency toward better echocardiographic midterm results than patients with open bands and may, therefore, benefit from improved repair durability.