Balakrishnan Mahesh

Prolonged Stay in Intensive Care Unit Is a Powerful Predictor of Adverse Outcomes After Cardiac Operations

BACKGROUND The aim of this study was to examine the impact of prolonged intensive care unit (ICU) stay on in-hospital mortality and long-term survival. METHODS Prospectively collected data from 6,101 consecutive patients who underwent surgery between 2003 and 2007 were analyzed. Prolonged ICU stay was defined as a total duration of ICU stay of 3 days or more postoperatively, including readmissions; patients with an ICU stay less than 3 days were identified as controls. Univariate and multiple variable analyses were performed to identify risk factors associated with prolonged ICU stay. RESULTS Of 6,101 patients, 1,139 (18.7%) patients had a prolonged ICU stay. These patients had a higher ICU mortality (10%) compared with controls (0.6%; p < 0.001). On discharge from the ICU, their hospital mortality was still 6-fold higher (1.2%) compared with controls (0.2%; p < 0.001). Finally, the patients who had prolonged ICU stays had lower survival after discharge from the ICU-89.2% and 81.2% at 1 year and 3 years, respectively, compared with 97.8% and 93.6%, respectively, for controls (p < 0.001). Multiple variable analysis revealed prolonged ICU stay to be an independent predictor of prolonged hospital stay, higher hospital mortality, and poorer long-term survival (all p < 0.001). CONCLUSIONS Prolonged ICU stay is an important predictor of adverse immediate, short-term, and long-term outcomes after cardiac operations.

Concomitant lung cancer resection and lung volume reduction surgery.

Patients who are offered concomitant surgery are highly selected and must satisfy the strict criteria set out for both LVRS and cancer surgery. Several evaluative processes have been reported for the selection of suitable patients. These various evaluative processes, together with the physical condition of the patient and the surgeons experience, help to best select patients suitable for combined surgical resection. Several intraoperative strategies are available for dealing with a patient who has concomitant lung cancer and severe emphysema. The choice of technique depends on the location and size of the tumor, the severity and distribution of the emphysema, and the surgeons experience and preference. Lung volume reduction surgery in well-selected patients who have severe emphysema results in postoperative improvement of symptoms and measured pulmonary function. The combination of lung cancer resection with LVRS offers selected patients who have concomitant early lung cancer and severe emphysema the opportunity to undergo resection of their cancer with improvement rather than further reduction in their pulmonary function. By traditional criteria these patients would otherwise be considered unsuitable surgical candidates because of the limited pulmonary function.

Role of concomitant tricuspid surgery in moderate functional tricuspid regurgitation in patients undergoing left heart valve surgery

Functional tricuspid regurgitation (FTR) is frequently present in patients undergoing aortic, and particularly mitral valve, surgery. Untreated FTR may lead to right heart failure. Reoperative cardiac surgery for late FTR is associated with high morbidity and mortality. Therefore, severe FTR has emerged as a Class I indication for concomitant tricuspid valve surgery in patients undergoing left valve surgery. Concomitant tricuspid valve surgery during left heart valve surgery to address moderate and mild FTR is controversial. This review addresses this issue and proposes an algorithm for the treatment of FTR in patients undergoing left heart valve surgery.

Pulmonary endarterectomy is effective and safe in patients with haemoglobinopathies and abnormal red blood cells: the Papworth experience†.

OBJECTIVES Patients with haemoglobinopathies and congenital haemolytic anaemia constitute a unique population more predisposed to developing chronic thromboembolic pulmonary hypertension (CTEPH). Although pulmonary endarterectomy (PEA) is accepted as the best treatment for CTEPH, PEA in these patients poses significant practical challenges. Apart from a few case reports, the results of PEA in this patient population have not been previously reported. The aim of this study was to review the outcome of PEA in this patient population. METHODS We performed a retrospective analysis, from our dedicated CTEPH database, of all patients who underwent PEA surgery and had abnormal haemoglobin or congenital haemolytic anaemia. We reviewed diagnosis, exchange transfusions on cardiopulmonary bypass, preoperative and postoperative pulmonary haemodynamic and functional data and outcomes for this group. Paired data analysis was performed by Students t-test; P < 0.05 was statistically significant. RESULTS Between the start of our PEA programme in 1997 and April 2015, we performed PEA in 19 patients with haemoglobinopathy or congenital haemolytic anaemia. The mean age was 52 ± 15 years. There were 9 patients with sickle cell trait, 2 with coexisting alpha+ thalassaemia trait, 2 patients with HbSC disease, 2 patients with beta-thalassaemia major, 3 patients with hereditary spherocytosis, 2 patients with stomatocytosis (one with the cryohydrocytosis subtype) and 1 patient with HbC trait. In the 9 HbAS patients, the mean HbS% was 31.9 ± 6%, and in the HbSC patients, the mean HbS% was 46.5 ± 1.3% preoperatively. To reduce this HbS to ≤20%, for safe PEA with deep hypothermic circulatory arrest, we used exchange blood transfusion. Immediately postoperatively, there was a significant improvement in pulmonary vascular resistance (938 ± 462 to 260 ± 167 dyne s cm(-5); P < 0.0001). One patient died 81 days following surgery; 18 patients are alive at a median follow-up of 3.4 ± 3 years. Six months postoperatively, the patients showed significant improvement in New York Heart Association status (P < 0.0001), and in 6-min walk distance from 251 ± 111 to 399 ± 69 m (P < 0.0001). CONCLUSIONS Results of PEA in this complex patient group were satisfactory. Expert haematological advice is important and exchange blood transfusions may be necessary. The presence of abnormal haemoglobin does not contra-indicate PEA surgery.

Tamponade by an expanding left ventricular pseudoaneurysm: A unique presentation.

Left ventricular free wall rupture secondary to myocardial infarction is an uncommon but catastrophic event requiring emergency surgery. We describe a unique presentation of left ventricular free wall rupture as delayed tamponade caused by a gradually expanding pseudoaneurysm compressing the left atrium, leading to pulmonary congestion that required increasing respiratory support to maintain oxygenation, and necessitated emergency surgery. We discuss the options available to treat pseudoaneurysms due to left ventricular free wall rupture.

Stenting of the ascending aorta: a stent too far?

A 45-year old woman with then unknown Loeys-Dietz syndrome (LDS) presented in 2007 with aneurysms involving the entire thoraco-abdominal aorta, but sparing the aortic root and valve. She underwent debranching of the aortic arch, followed by stenting of entire distal ascending aorta, arch and descending aorta. Two years later, a diagnosis of LDS was established. Five years later, she re-presented with severe aortic regurgitation in a dilated aortic root, requiring aortic root replacement. We present the challenges involved in performing aortic root replacement in the presence of stents within the ascending aorta.

A novel technique for pulmonary endarterectomy in the presence of patent coronary artery bypass grafts

Pulmonary endarterectomy (PEA) is the definitive surgical treatment for chronic thromboembolic pulmonary hypertension, with excellent short- and long-term results. PEA following previous coronary artery bypass graft surgery carries a risk of damage to patent grafts, as well as the risk of inadequate myocardial protection, especially when a patent pedicled internal thoracic artery graft is present. We report a technique where PEA may be safely and successfully accomplished ensuring, adequate clearance of bilateral pulmonary thromboembolic disease via a right pulmonary arteriotomy, avoiding the patent bypass grafts overlying the pulmonary trunk, while ensuring adequate myocardial protection.