Dimitrios V. Avgerinos

Blood conservation strategies in cardiac surgery: more is better

OBJECTIVES Recent data show that up to 50% of heart procedures require blood transfusion, which can have adverse long- and short-term outcomes for the patient. This led to the updated 2011 Society of Thoracic Surgery (STS)/Society of Cardiovascular Anesthesiologists (SCA) guidelines in an attempt to adopt more effective blood conservation techniques. We present our results after the implementation of a more aggressive strategy for intraoperative blood conservation in cardiac surgery. METHODS Our cardiac surgery database was reviewed retrospectively, comparing outcomes from two different time periods, after the implementation of a more effective two-way blood conservation strategy beginning in March 2012: more aggressive intraoperative autologous donation (IAD) based on a newly constructed nomogram, and the use of a shorter length circuit of the cardiopulmonary bypass (CPB) which allowed for lower fluid volume as a prime. The method of retrograde autologous priming (RAP) was the same for both time periods. RESULTS A total of 1126 patients (Group 1) were studied in a 12-month period (March 2012-February 2013) after the implementation of the new strategy, and compared with 3758 patients (Group 2) of the previous 36-month period (March 2009-February 2012). There was a significant reduction in the percent change of the intraoperative haematocrit between Groups 1 and 2 (14 vs 28%, P = 0.01), with an increase in the mean IAD volume (655 vs 390 ml, P = 0.02) and a reduction in the CPB priming volume (1000 vs 1600 ml, P = 0.03). Group 1 required significantly less blood transfusions in the perioperative period (29 vs 49%, P = 0.02) and had significantly reduced postoperative rates of respiratory failure (3 vs 7%, P = 0.03), pneumonia (1 vs 3.1%, P = 0.01), chest tube output (350 vs 730 ml, P = 0.01), reoperation for bleeding (1.2 vs 2.5%, P = 0.04) and length of stay (6.1 vs 8.2 days, P = 0.05). CONCLUSIONS Blood conservation is safe and effective in reducing transfusions in cardiac surgery, minimizing perioperative morbidity and mortality. Aggressive IAD and low CPB prime, along with effective RAP, is the three-way blood conservation strategy that leads to improved outcomes in cardiac surgery.

Primary Adrenal Melanoma With Inferior Vena Caval Thrombus

Primary adrenal melanoma is a rare tumor. Most lesions are confined to the adrenal gland, without extension to surrounding structures. We report a primary adrenal melanoma discovered during an evaluation for pulmonary embolism. Tumor thrombus was present in the inferior vena cava extending into the right atrium. A complete resection was obtained using cardiopulmonary bypass and profound hypothermic circulatory arrest. Long-term survival with melanoma is still limited, regardless of the organ of origin.

Unplanned Staged Hybrid Management of Postmyocardial Infarction Ventricular Septal Defect

Ventricular septal defect (VSD) is an uncommon but potentially deadly complication of transmural myocardial infarction (MI). Emergency surgical treatment has traditionally offered the best chance for survival. However, operative intervention is associated with high mortality and can be complicated by a recurrent VSD due to tissue friability around the infarcted area. Percutaneous catheter-based closure techniques can be used to treat these critically ill patients, offering a less invasive and less morbid technique. This case demonstrates the successful application of an unplanned, staged hybrid approach utilizing initial percutaneous and subsequent surgical repair after recovery of tissue integrity.

A Rare Case of Cystic Schwannoma of the Portal Triad

Schwannomas can occur anywhere throughout the body and have often been mistaken for more-sinister lesions, especially when found in relation to the pancreas. Clinical symptoms range from none to vague abdominal pain, back pain, anorexia, weight loss, vomiting, jaundice, and episodes of cholangitis and gastrointestinal bleeding. Preoperative diagnosis is difficult, and endoscopic ultrasound with fine-needle aspiration is often limited in specificity. Given the low statistical likelihood of schwannomas, therapy is usually targeted at the possibility of pancreatic cystadenoma/cystadenocarcinoma. Simple enucleation is usually the preferred treatment, and diagnosis can be established at the time of operation by frozen section. Schwannomas can be malignant, but preoperative imaging and pathology can help establish the benign nature of most specimens. Patients typically do well with resolution of symptoms. Here we present the case of a patient with abdominal pain and a peripancreatic mass observed with computed tomography, who was found to have a cystic schwannoma extending from the portal triad. The mass was removed and the patient was discharged without complications.

Diagnostic Cardiac Catheterization in the Pediatric Population

Although the utility of diagnostic cardiac catheterization in the clinical setting has diminished over the last years, due to the emergence of noninvasive imaging modalities, such as echocardiography, magnetic resonance imaging and computed tomography, catheterization for diagnostic reasons still constitutes a valuable tool in certain parts in the workup of pediatric heart disease. As a result, awareness of the main aspects of diagnostic catheterization is of great importance for the clinical cardiologist. In this article, the main variables measured and the main actions performed during diagnostic cardiac catheterization in children are discussed.

Hybrid Coronary Revascularization: Present Indications and Future Perspective

Opinion statementHybrid coronary revascularization (HCR) strategy consists of minimal invasive left internal mammary artery to left anterior descending bypass grafting and percutaneous coronary intervention (PCI) of the remaining lesions. HCR combines the known benefits of the LIMA-to-LAD graft (LIMA: left internal mammary artery, LAD: left anterior descending) and drug eluting stent (DES) to non-LAD regions and is currently reserved for particularly high-risk patients with favorable anatomy. Despite the lack of multicenter randomized trials, several small non-randomized studies have shown that HCR is safe with low mortality rates, low morbidity, and shorter intensive care unit and hospital stay. Up to date, HCR appears to be a promising and cost-effective alternative for CABG in the treatment of multivessel coronary artery disease in a selected patient population.

eComment. Spinal cord protection during thoracoabdominal aneurysm repair

The study ‘Novel application of acetazolamide to reduce cerebrospinal fluid production in patients undergoing thoracoabdominal aortic surgery’ by Jafarzadeh and associates [1] comes to cover a large practice gap in the prolepsis of spinal cord ischaemia in patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair. Our practice so far is to protect the spinal cord during TAAA repair with a spinal drain that is kept for 48-72 h in the postoperative period. Strict guidelines are applied for the management of the drain for optimal protection. In addition, permissive hypothermia and liberal use of alpha-agonists in order to increase the mean arterial pressure during the postoperative period is the standard routine. Finally, recent studies have stressed that adding intrathecal papaverine to the neuroprotective protocol for descending thoracic aneurysm and TAAA repairs may enhance spinal cord perfusion and provide additional spinal cord protection [2]. We agree with the authors that in cases of contra-indication to the use of a spinal drain or the inability to insert it, the use of other agents that increase spinal cord perfusion is promising. There is an imperative need of a randomized trial, which will determine the efficacy of acetazolamide in the spinal cord protection during TAAA repair.

A Unique Case of Recurrent Metachronous Volvulus of the Gastrointestinal Tract

Colonic volvulus is an uncommon disease that predisposes patients to bowel obstruction in both the adult and pediatric population. The international literature offers few reports of synchronous or metachronous volvulus of 2 organs of the gastrointestinal tract. We describe a unique case of a patient who presented with recurrent metachronous volvulus of the sigmoid colon, cecum, and stomach. The patient underwent multiple operations for bowel obstruction, lysis of adhesions, and colon resection. The interesting intraoperative findings were a very long mesentery and peritoneal attachments of the intraabdominal gastrointestinal organs that made the stomach and colon extremely mobile and thus susceptible to volvulus. Prophylactic pexis of the cecum and the stomach during the first operation, in light of the elongated mesentery, may have prevented the subsequent episodes of volvulus.

eComment. Aneurysms of the pulmonary artery

The present article is one of the largest reported series of surgically treated aneurysms of the pulmonary artery [1]. These aneurysms are often going undiagnosed due to the lack of specific symptomatology. In many cases, the first symptom is spontaneous rupture with sudden death. Thus, it is imperative to follow-up the patients with a known aneurysm of the pulmonary artery and surgically repair them once they reach a specific diameter, exactly as we do with aortic aneurysms. However, the general rule of 5.5 cm cutoff that applies to the ascending and arch aortic aneurysms cannot necessarily be applied to the pulmonary artery, due to its different wall thickness and layers. Thus, most authors recommend elective repair of the pulmonary artery aneurysm when it has reached around 6 cm in diameter or when symptoms develop [1,2], mostly due to compression on the left main coronary artery. Rapid growth would also warrant an operative approach. Finally, meticulous preoperative diagnosis and work-up is necessary, since many aneurysms of the pulmonary artery co-exist with congenital cardiac anomalies, most often stenosis of the pulmonic valve (below, above, or at the valve level). For that reason, intraoperative transoesophageal echocardiography is of utmost importance. The concomitant pathology needs to be addressed at the same operative setting in order to avoid future problems.

Therapeutic Utilities of Pediatric Cardiac Catheterization

In an era when less invasive techniques are favored, therapeutic cardiac catheterization constantly evolves and widens its spectrum of usage in the pediatric population. The advent of sophisticated devices and well-designed equipment has made the management of many congenital cardiac lesions more efficient and safer, while providing more comfort to the patient. Nowadays, a large variety of heart diseases are managed with transcatheter techniques, such as patent foramen ovale, atrial and ventricular septal defects, valve stenosis, patent ductus arteriosus, aortic coarctation, pulmonary artery and vein stenosis and arteriovenous malformations. Moreover, hybrid procedures and catheter ablation have opened new paths in the treatment of complex cardiac lesions and arrhythmias, respectively. In this article, the main therapeutic utilities of cardiac catheterization in children are discussed.