Erez Sharoni

Colchicine for the Prevention of Postpericardiotomy Syndrome

Background: Postpericardiotomy syndrome (PPS) is a troublesome complication of cardiac surgery, occurring in 10–45% of cases. Accepted modalities of treatment include nonsteroidal anti-inflammatory drugs, corticosteroids, and pericardiectomy in severe cases. The optimal method for prevention of PPS has not been established. Recent trial data have shown that colchicine is efficient in the secondary prevention of recurrent episodes of pericarditis. The iam of the present study was to evaluate the possible benefit of colchicine for the primary prevention of PPS in patients after cardiac surgery. To the best of our knowledge, this is the first study addressing this issue. Patients and Methods: A prospective, randomized, double-blind design was used. The initial study group included 163 patients who underwent cardiac surgery in two centers in Israel between October 1997 and September 1998. On the 3rd postoperative day, the patients were randomly assigned to receive colchicine (1.5 mg/day) or placebo for 1 month. All were evaluated monthly for the first 3 postoperative months for development of PPS. Results: 52 of the 163 patients were excluded because of postoperative complications, noncompliance, or gastrointestinal side effects of treatment. Of the 111 patients who completed the study, 47 (42.3%) received colchicine and 64 (57.7%) placebo. There was no statistically significant difference between the groups in clinical or surgical characteristics. PPS was diagnosed in 19 patients (17.1%), 5/47 cases (10.6%) in the colchicine group and 14/64 (21.9%) in the placebo group. The difference showed a trend toward statistical significance (p < 0.135). Conclusions: Colchicine may be efficacious for the prevention of PPS in patients after cardiac surgery. Further evaluations in larger clinical trials are warranted.Hintergrund: Das Postperikardiotomie-Syndrom (PPS) ist eine Folgeerscheinung nach Herzoperationen und tritt bei 10–45% der Patienten auf. Die Behandlung kann mit nichtsteroidalen Entzündungshemmern, Kortikosteroiden und in schweren Fällen durch eine Perikardektomie erfolgen. Ein optimales Verfahren zur Vermeidung des PPS gibt es noch nicht. Neuere klinische Studien zeigten, dass Colchicin bei der Sekundärprävention einer wiederauftretenden Perikarditis wirksam ist. Es war das Ziel der vorliegenden Untersuchung, die Wirkung von Colchicin bei der Primärprävention des PPS zu überprüfen. Eine vergleichbare Untersuchung gibt es unseres Wissens noch nicht. Patienten und Methoden: Die Untersuchung erfolgte prospektiv, randomisiert und doppelblind. In der ursprüglichen Studiengruppe wurden 163 Patienten mit geplanter Herzoperation in zwei Zentren in Israel zwischen Oktober 1997 und September 1998 eingeschlossen. Am 3. postoperativen Tag erhielten die Patienten randomisiert über 1 Monat entweder täglich 1,5 mg Colchicin oder Plazebo. Bei allen Patienten wurde das Auftreten des PPS nach 1, 2 und 3 Monaten überprüft. Ergebnisse: 52 der 163 Patienten wurden wegen postoperativer Komplikationen. Non-Compliance oder gastrointestinalen Nebenwirkungen von der Studie ausgeschlossen. Von den 111 verbliebenen Patienten erhielten 47 (42,3%) Colchicin und 64 (57,7%) Plazebo. Es gab keinen statistisch signifikanten Unterschied in klinischen oder operativen Parametern. Das PPS trat bei insgesamt 19 Patienten (17,1%) auf. In der Colchicin-Gruppe trat es bei 10.6% (5/47) und in der Plazebo-Gruppe bei 21.9% (14/64) der Patienten auf. Der Unterschied war aber nicht statistisch signifikant (p < 0,135). Schlussfolgerung: Weitere klinische Studien sind erfolgreich um die Wirksamkeit von Colchicin bei der Verhinderung des PPS bei Patienten nach Herzoperationen zu sichern.

The effect of cardiac angiography timing, contrast media dose, and preoperative renal function on acute renal failure after coronary artery bypass grafting.

OBJECTIVE Our objective was to assess the effect of the timing of cardiac angiography, contrast media dose, and preoperative renal function on the prevalence of acute renal failure after cardiac surgery. METHODS Data on 395 consecutive patients who underwent coronary artery bypass grafting were prospectively collected. Creatinine clearance was estimated by the Cockcroft-Gault equation. Patients were divided into 3 groups according to the time between cardiac angiography and surgery (group A, < or = 1 day; group B, > 1 day and < or = 5 days; group C, > 5 days). Patients who underwent a salvage operation or were receiving dialysis before surgery were excluded. Acute renal failure was defined as 25% decrease from baseline of estimated creatinine clearance and estimated creatinine clearance of 60 mL/min or less on postoperative day 3. Owing to differences in preoperative characteristics between groups, propensity score analysis was used to adjust those differences. RESULTS Acute renal failure developed in 13.6% of patients. Hospital mortality was 3.3% and was higher in patients in whom acute renal failure developed (22%) versus those in whom it did not (0.3%; P < .001). Multivariable analysis identified preoperative estimated creatinine clearance of 60 mL/min or less (odds ratio [OR], 7.1), operation within 24 hours of catheterization (OR = 3.7), use of more than 1.4 mL/kg of contrast media (OR = 3.4), lower hemoglobin level (OR = 1.3), older age (OR = 1.1), and lower weight (OR = 0.95) as independent predictors of postoperative acute renal failure. Analysis of interaction between contrast dose and time of surgery revealed that high contrast dose (>1.4 mL/kg) predicted acute renal failure if surgery was performed up to 5 days after angiography. CONCLUSIONS Whenever possible, coronary bypass grafting should be delayed for at least 5 days in patients who received a high contrast dose, especially if they also have preoperative reduced renal function.

Antibiotic prophylaxis in cardiac surgery: systematic review and meta-analysis

BACKGROUND Antibiotic prophylaxis is recommended in cardiac surgery. Current debate concerns the type of antibiotic(s), dosing and the duration of prophylaxis. METHODS Systematic review of randomized controlled trials comparing one antibiotic regimen versus another in cardiac surgery. We searched The Cochrane Library, PubMed, LILACS, conference proceedings and bibliographies. Two reviewers independently extracted the data. The primary outcome was deep sternal wound infections (DSWIs). Meta-analysis was performed using the Mantel-Haenszel fixed-effect method. Risk ratios (RRs) with 95% confidence intervals (95% CIs) are reported. RESULTS Fifty-nine trials were included. There were no significant differences in DSWI or all other categories of surgical site infections (SSIs) for antibiotic prophylaxis with β-lactams comprising a Gram-negative spectrum of coverage versus prophylaxis targeting Gram-positive bacteria, but the former led to a significantly lower rate of post-operative pneumonia (RR 0.68, 95% CI 0.51-0.90) and all-cause mortality (RR 0.66, 95% CI 0.47-0.92). In trials comparing different antibiotic regimens for different durations, prophylaxis duration of ≤24 h post-operation led to higher rates of DSWI (RR 1.83, 95% CI 1.25-2.66), any sternal SSI, surgical interventions for SSI and endocarditis compared with longer duration prophylaxis. There was no advantage of regimens lasting >48 h post-operation. In the comparison of glycopeptides versus β-lactams, an advantage of glycopeptides was observed when comparators were given for similar duration and for β-lactams when given for a longer duration than the glycopeptides. There was no significant advantage of high antibiotic dosing. CONCLUSIONS Evidence supports second- or third-generation cephalosporins for cardiac surgery prophylaxis and points at a possible advantage of prophylaxis prolongation up to 48 h post-operatively.

Off-Pump Coronary Artery Bypass Surgery for Significant Left Ventricular Dysfunction: Safety, Feasibility, and Trends in Methodology Over Time - An Early Experience

Objective: To examine the safety and applicability of off pump coronary artery bypass surgery (OPCAB) in patients with significant left ventricular dysfunction and to discuss the clinical implications for the surgical methods. Design: Retrospective study. Setting: Tertiary care university affiliated referral centre. Participants: 353 consecutive patients with preoperative left ventricular ejection fraction ⩽ 35% who underwent coronary artery bypass over a three year period. Main outcome measures: Postoperative morbidity and mortality. Methods: 144 patients operated by OPCAB were compared with 209 patients operated by conventional coronary artery bypass. Multivariate and univariate analyses were performed on the pre- and postoperative variables to predict risk factors associated with hospital morbidity and mortality. Results: Patients in the OPCAB group were more likely to be women and to have congestive heart failure, chronic obstructive pulmonary disease, hypertension, and diabetes; patients in the on pump group were more likely to have had a recent myocardial infarction and to have more severe angina pectoris and an urgent/emergent status. The groups did not differ significantly in length of stay, major postoperative complication rates, or mortality. Comparison of the impact of the procedures on surgical methods over time showed an increase in the use of OPCAB (13% to 67%), without any impact on morbidity or mortality. Conclusions: OPCAB is feasible and applicable for patients with depressed left ventricular function. This high risk group can potentially benefit from the off pump approach.

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.

Chest reconstruction in asphyxiating thoracic dystrophy

Asphyxiating thoracic dystrophy is a rare, complex malformation with a broad spectrum of clinical expression. Surgery is indicated only in severe cases in which failure to intervene will result in progressive pulmonary damage and eventual death. Conventional surgical techniques for expanding the thoracic cage diameter by sternotomy and the insertion of a metal prosthesis for anterior chest wall stability usually provide these patients with the time needed for thoracic cage growth. However, some of the most severe cases may require a two-stage approach. Hence, management should be directed toward resolving immediate ventilatory problems and minimizing secondary damage to the lungs caused by prolonged ventilatory support.

Coronary artery operation in patients after breast cancer therapy.

OBJECTIVE The purpose of this investigation was to retrospectively study the outcome of patients undergoing coronary artery operation who were previously treated for breast cancer. METHODS Between July 1992 and December 1996, 28 patients with a history of breast cancer underwent coronary artery bypass graft operation and were randomly matched against a noncancer group of similar size (n = 36) to allow for comparison of their preoperative characteristics, operative course, and postoperative outcome. RESULTS The incidence of sternal wound infection was significantly higher in the cancer group than in the control group (25% versus 6%; p = 0.027). Postoperative noncardiac chest pain occurred more frequently in the cancer group than in the control group (52% versus 31%; not significant). In the study group, radiotherapy and recent myocardial infarction were the only two independent factors associated with sternal wound complications. Patients with a less than 17-year interval between the breast cancer therapy and the coronary artery operation had a higher incidence of sternal wound infection (46%) as opposed to patients with a longer time interval (7%; p = 0.028; odds ratio = 12). Sternal wound complications were more frequent in patients with a history of right-sided breast cancer (50%) compared with left-sided lesions (12.5%; p = 0.068; odds ratio = 7). CONCLUSIONS Coronary artery operation in patients after breast cancer therapy may be associated with an increased sternal wound infection rate. To decrease this risk of infection, an approach through a right thoracotomy, minimally invasive techniques, the use of skeletonized internal mammary artery, and broad spectrum antibiotic therapy may be considered.

Transesophageal echocardiography evaluation and follow-up of left main coronary artery patch angioplasty.

OBJECTIVE Isolated ostial stenosis of the left main coronary artery is a rare but serious condition. The treatment is surgical with two options: coronary artery bypass grafting or surgical angioplasty of the left main coronary artery. Assessing surgical results as well as follow-up were traditionally done by angiography. METHODS We describe the use of transesophageal echocardiography (TEE) for evaluating and follow the surgical left main coronary artery (LMCA) angioplasty results in eight patients with isolated ostial left main stenosis. RESULTS All patients were alive and free of ischemic events 8 months to 7 years post-surgery. TEE demonstrated a widely opened left main coronary artery with a good flow. CONCLUSIONS Surgical angioplasty is an alternative option for treating ostial LMCA stenosis. TEE is an additional excellent non-invasive technique for assessing left main anatomy pre- and postoperatively, as well as being on of the quality control tools for evaluating new surgical techniques.

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.