Alon Stamler

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

OBJECTIVE Open-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. DESIGN The study was carried out as a retrospective analysis in the Department of Cardiothoracic Surgery in a large university-affiliated hospital. PATIENTS 115 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. METHODS The 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. RESULTS The 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). CONCLUSION Patients 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

BACKGROUND Postoperative 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. PATIENTS AND DESIGN A 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. RESULTS The 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. CONCLUSIONS Female gender is apparently not an independent risk factor for coronary artery bypass graft mortality in this patient group.

Preparation of the internal thoracic artery by vasodilator drugs: is it really necessary? A randomized double-blind placebo-controlled clinical study

OBJECTIVE The internal thoracic artery has become the conduit of choice for coronary artery bypass grafting. To avoid spasm of the artery, and increases in its diameter and flow, various vasodilators have been used either intraluminally or by topical application by different surgeons. In order to define the best vasodilating agent for preparation of the internal thoracic artery, a randomized double-blind placebo-controlled clinical study was performed in a group of patients submitted for elective coronary artery bypass grafting. METHODS AND RESULTS Eighty (80) consecutive patients submitted for elective first time coronary artery bypass grafting were randomly subdivided into five treatment groups. Free flow of the left internal thoracic artery was measured using an electromagnetic flow meter. The first measurement was performed shortly after the internal thoracic artery was dissected from the chest wall and the second just prior to performing distal anastomosis to the left anterior descending coronary artery. During the time interval between the two measurements the internal thoracic artery was immersed in a special applicator tube containing 20 ml solution of one of the following drugs: papaverin 2 mg/ml, nitroglycerin 1 mg/ml, verapamil 0.5 mg/ml, nitroprusside 0.5 mg/ml, normal saline 0.9%. RESULTS No statistically significant differences were found between the groups in respect to age, body surface area, bypass time, cross clamping time, and time interval between the two flow measurements. Mean arterial pressure at the time of the first and second internal thoracic artery flow measurements did not show statistically significant differences either within or between the groups. In all five groups, the free flow of the internal thoracic artery increased significantly with time. However, no statistically significant differences were shown between the five groups with respect to second flow (P = 0.2). CONCLUSIONS Within the limits of our study design, we suggest that preparation of the LITA by topical vasodilator drugs using a special applicator tube does not result in a significantly superior free flow than placebo.

Successful resuscitation of a patient with acute massive pulmonary embolism using emergent embolectomy

Acute massive pulmonary embolism is associated with a high mortality rate. Prompt diagnosis and treatment are mandatory for a successful outcome. Although thrombolysis is effective, it is associated with a high rate of bleeding complications. This report describes the use of emergent pulmonary embolectomy as an effective and aggressive therapeutic approach to a massive saddle pulmonary embolism in a 66-year-old woman. With the application of specific surgical techniques and good interdisciplinary cooperation, pulmonary embolectomy may serve as more than a last resort for the management of this clinically unstable and dangerous condition.

Advantages of the ultrasonic harmonic scalpel for radial artery harvesting.

The aim of the study was to examine the safety and effectiveness of the Harmonic Scalpel® for reducing spasm caused by thermal injury during radial artery harvesting. The study sample included 100 candidates undergoing coronary artery bypass grafting. In half the patients, radial artery harvesting was performed using the ultrasonic Harmonic Scalpel equipped with coagulating curved shears and a 14 cm scissor-grip handle and in the other half, hemostatic clips, scissors, and minimal electrocautery were employed. Comparison of outcome between the groups showed that radial artery harvesting with the Harmonic Scalpel was associated with a shorter harvesting time, lower frequency of spasm, larger internal diameter of the radial artery graft, and a significantly reduced need for clips to control bleeding than the standard method. In addition, there were no cases of hematoma or superficial wound infection in the arm, and no postoperative reduction in soft touch sensation or objective pin-prick sensation. In conclusion, the Harmonic Scalpel provides excellent control of bleeding without the need for potentially damaging electrocautery, and with a markedly decreased use of hemostatic clips. Harvesting time is also shorter. The minimized thermal injury decreases the rate of radial artery spasm. Further studies using additional objective measures are currently underway to confirm these findings.

Early oral analgesia after fast-track cardiac anesthesia.

Objectif L’analgesie orale apres la technique acceleree d’anesthesie cardiaque n’a pas ete etudiee. Le but de cette etude etait de comparer deux regimes d’analgesie a l’oxycodone per os.PurposeOral analgesia after “fast-track” cardiac anesthesia has not been explored. The aim of this study was to compare two oral oxycodone analgesic regimens.MethodsOne hundred-twenty patients scheduled for coronary artery bypass grafting were randomly assigned postoperatively to receive immediate-release oxycodone 5 mg and acetaminophen 325 mg (Percocet-5) (group I)per os four times daily, or controlled-release oxycodone 10 mg (OxyContin) (group II)per os every 12 hr and placebo twice daily. Acetaminophen 500 mgper os was used as first-line rescue medication, and immediate-release oxycodone (syrup form) 5 mgper os as second-line rescue medication. Pain intensity was assessed with a visual analogue scale on the first postoperative day, the morning after extubation, and thereafter four times daily for four days. Use of rescue medication and adverse events were recorded.ResultsBaseline demographic and operation-related characteristics were similar in both groups. While pain control was good in both groups, the immediate-release group experienced less pain on all postoperative days (P = 0.003), required significantly less rescue medication, and had fewer adverse effects such as somnolence and nausea.ConclusionPeroral oxycodone is effective for early pain control after fast-track cardiac anesthesia. Immediate-release oxycodone/acetaminophen appears to provide better analgesia and fewer side effects compared to controlled-release oxycodone.RésuméObjectifL’analgésie orale après la technique accélérée d’anesthésie cardiaque n’a pas été étudiée. Le but de cette étude était de comparer deux régimes d’analgésie à l’oxycodone per os.MéthodesCent- vingt patients devant subir une chirurgie de revascularisation myocardique ont été aléatoirement répartis en deux groupes après l’opération : le groupe I a reçu 5 mg d’oxycodone à libération immédiate et 325 mg d’acétaminophène (Percocet- 5) per os quatre fois par jour, et le groupe II a reçu 10 mg d’oxycodone à libération contrôlée (OxyContin) per os chaque 12 h et un placebo deux fois par jour. L’acétaminophène (500 mg per os) a été utilisé comme médicament de sauvetage de première intention et l’oxycodone (5 mg per os à libération immédiate sous forme de sirop) comme médicament de sauvetage de seconde intention. L’intensité de la douleur a été évaluée à l’aide d’une échelle visuelle analogue le premier jour après l’opération, le matin suivant l’extubation, puis quatre fois par jour pendant quatre jours. L’utilisation de médicaments de sauvetage ainsi que les complications ont été enregistrées.RésultatsLes caractéristiques démographiques de base ainsi que celles en rapport avec l’opération furent similaires dans les deux groupes. Bien que le contrôle de la douleur ait été bon dans les deux groupes, les patients du groupe à libération immédiate ont ressenti moins de douleur durant les jours suivant l’opération (P = 0,003), ont eu besoin d’une dose significativement moindre de médicaments de sauvetage, et ont subi moins d’événements négatifs tels que la somnolence ou la nausée.ConclusionL’oxycodone peroral est efficace pour un contrôle de la douleur précoce après une technique accélérée d’anesthésie cardiaque. L’oxycodone / acétaminophène à libération immédiate semble fournir une meilleure analgésie et moins d’effets secondaires que l’oxycodone à libération contrôlée.

Optimizing early extubation after coronary surgery.

Early extubation after isolated coronary artery bypass surgery was assessed retrospectively in 545 of 779 patients treated by the same surgical team over one year. All underwent extubation within 10 hr of arrival at the cardiothoracic intensive care unit: 343 in < 6 hr and 202 in 6–10 hr. Operative mortality was 2.2%. Group comparisons revealed that patients who had earlier extubation were younger (61 vs. 66 years; p < 0.001), more likely to be male (72.5% vs. 61.3%; p < 0.05), with a shorter aortic crossclamp time (49.2 ± 15.0 vs. 53.3 ± 14.0 min; p < 0.05), cardiopulmonary bypass time (65 ± 18.4 vs. 72.2 ± 19.2 min; p < 0.05), intensive care unit stay (18.8 ± 5.6 vs. 22.4 ± 3.2 hr; p < 0.05) and postoperative hospital stay (5.2 ± 2.2 vs. 6.0 ± 2.4 days; p = 0.01). Extubation < 6 hr after cardiopulmonary bypass may accelerate recovery. The finding of no significant differences in clinical parameters between the groups suggests that efforts to further reduce the time to extubation might be worthwhile.

L’analgésie orale précoce après la technique accélérée d’anesthésie cardiaque

Objectif L’analgesie orale apres la technique acceleree d’anesthesie cardiaque n’a pas ete etudiee. Le but de cette etude etait de comparer deux regimes d’analgesie a l’oxycodone per os.PurposeOral analgesia after “fast-track” cardiac anesthesia has not been explored. The aim of this study was to compare two oral oxycodone analgesic regimens.MethodsOne hundred-twenty patients scheduled for coronary artery bypass grafting were randomly assigned postoperatively to receive immediate-release oxycodone 5 mg and acetaminophen 325 mg (Percocet-5) (group I)per os four times daily, or controlled-release oxycodone 10 mg (OxyContin) (group II)per os every 12 hr and placebo twice daily. Acetaminophen 500 mgper os was used as first-line rescue medication, and immediate-release oxycodone (syrup form) 5 mgper os as second-line rescue medication. Pain intensity was assessed with a visual analogue scale on the first postoperative day, the morning after extubation, and thereafter four times daily for four days. Use of rescue medication and adverse events were recorded.ResultsBaseline demographic and operation-related characteristics were similar in both groups. While pain control was good in both groups, the immediate-release group experienced less pain on all postoperative days (P = 0.003), required significantly less rescue medication, and had fewer adverse effects such as somnolence and nausea.ConclusionPeroral oxycodone is effective for early pain control after fast-track cardiac anesthesia. Immediate-release oxycodone/acetaminophen appears to provide better analgesia and fewer side effects compared to controlled-release oxycodone.RésuméObjectifL’analgésie orale après la technique accélérée d’anesthésie cardiaque n’a pas été étudiée. Le but de cette étude était de comparer deux régimes d’analgésie à l’oxycodone per os.MéthodesCent- vingt patients devant subir une chirurgie de revascularisation myocardique ont été aléatoirement répartis en deux groupes après l’opération : le groupe I a reçu 5 mg d’oxycodone à libération immédiate et 325 mg d’acétaminophène (Percocet- 5) per os quatre fois par jour, et le groupe II a reçu 10 mg d’oxycodone à libération contrôlée (OxyContin) per os chaque 12 h et un placebo deux fois par jour. L’acétaminophène (500 mg per os) a été utilisé comme médicament de sauvetage de première intention et l’oxycodone (5 mg per os à libération immédiate sous forme de sirop) comme médicament de sauvetage de seconde intention. L’intensité de la douleur a été évaluée à l’aide d’une échelle visuelle analogue le premier jour après l’opération, le matin suivant l’extubation, puis quatre fois par jour pendant quatre jours. L’utilisation de médicaments de sauvetage ainsi que les complications ont été enregistrées.RésultatsLes caractéristiques démographiques de base ainsi que celles en rapport avec l’opération furent similaires dans les deux groupes. Bien que le contrôle de la douleur ait été bon dans les deux groupes, les patients du groupe à libération immédiate ont ressenti moins de douleur durant les jours suivant l’opération (P = 0,003), ont eu besoin d’une dose significativement moindre de médicaments de sauvetage, et ont subi moins d’événements négatifs tels que la somnolence ou la nausée.ConclusionL’oxycodone peroral est efficace pour un contrôle de la douleur précoce après une technique accélérée d’anesthésie cardiaque. L’oxycodone / acétaminophène à libération immédiate semble fournir une meilleure analgésie et moins d’effets secondaires que l’oxycodone à libération contrôlée.

Lipid metabolism and immunosuppressive therapy in heart transplant recipients

This study included 30 heart transplant patients with follow up to 6 years. The subjects were retrospectively divided in two groups based on the immunosuppressive therapy—cyclosporine or FK506. Total cholesterol blood levels were measured regularly together with the immunosuppressant drug levels and anti-lipidic treatmentrecorded. Concomitant therapy with low-dose steroids and azathioprine was similar in both groups. T-tests were performed to compare the mean values of the two groups.

Computer-enhanced thoracoscopic thymectomy with the Zeus telemanipulation surgical system.

Recent years have witnessed important progress in the use of minimally invasive robotic-enhanced surgical systems in cardiac and general thoracic interventions. We report the first-ever successful use of the Zeus robotic surgical system (Computer Motion, Inc, Goleta, CA) for the excision of an anterior mediastinal mass. Proper positioning of the thoracic ports for the robotic arms to permit a wide range of movement, is the key to the application of the system for intrathoracic cage operations. Other advantages of the system include three-dimensional voice controlled imaging, low-heat surgical field, and good exposure of the structures.