Fabiano Viana

Custodiol versus blood cardioplegia in complex cardiac operations: an Australian experience

OBJECTIVES A single or dual-dose strategy for myocardial protection is attractive in long operations, in avoiding the need to interrupt the procedure to re-administer cardioplegia. We hypothesized that a single administration of Bretschneider histidine-tryptophan-ketoglutarate (HTK) crystalloid solution (Custodiol) offers myocardial protection comparable with repeated tepid blood cardioplegia. METHODS We reviewed a prospectively compiled single-centre database containing all adult cardiac procedures performed from January 2005 to January 2011. Preoperative demographic and investigative data, operative variables and postoperative (30-day) mortality and morbidity were compared between the Custodiol and blood cardioplegia groups. The study primary endpoints were 30-day mortality, return to the operating theatre, myocardial infarction, stroke, postoperative requirement for an intra-aortic balloon pump, new renal failure, prolonged ventilation and re-admission to hospital within 30 days. Propensity score matching was performed to correct for any bias that may have been associated with the usage of Custodiol. RESULTS A total of 1900 cardiac surgical procedures were identified of which 126 (7%) utilized Custodiol and 1774 (93%) used blood cardioplegia as the primary cardioplegic agent. After propensity-score matching, we were able to match 71 Custodiol cases one-to-one to those receiving blood cardioplegia. There were no statistically significant differences noted for any of the endpoints studied after propensity-score matching. In particular, the proportion of mortality (blood cardioplegia: 1 vs Custodiol 4%, P = 0.63) any mortality/morbidity (blood cardioplegia: 35 vs Custodiol: 39% P = 0.46) was similar between the groups. CONCLUSIONS The use of Custodiol is convenient, simple and at least as safe as tepid blood cardioplegia for myocardial protection in complex cardiac operations. A randomized prospective comparison of myocardial protection strategies is warranted.

Gastrointestinal complications after cardiac surgery: 10-year experience of a single Australian centre

Gastrointestinal (GI) complications after cardiac surgery are uncommon, but are associated with high morbidity and mortality as well as significant hospital resource utilization.

Dynamic Four-dimensional Computed Tomography (4D CT) Imaging for Re-entry Risk Assessment in Re-do Sternotomy - First experience

BACKGROUND Repeat cardiac surgeries are well known to have higher rates of complications, one of the important reasons being injuries associated with re-do sternotomy. Routine imaging with CT can help to minimise this risk by pre-operatively assessing the anatomical relation between the sternum and the underlying cardiovascular structures, but is limited by its inability to determine the presence and severity of functional tethering and adhesions between these structures. However, with the evolution of wide area detector MD CT scanners, it is possible to assess the presence of tethering using the dynamic four-dimensional CT (4D CT) imaging technique. METHODS Nineteen patients undergoing re-do cardiac surgery were pre-operatively imaged using dynamic 4D CT during regulated respiration. The datasets were assessed in cine mode for presence of differential motion between sternum and underlying cardiovascular structures which indicates lack of significant tethering. RESULTS Overall, there was excellent correlation between preoperative imaging and intraoperative findings. The technique enabled our surgeons to meticulously plan the procedures and to avoid re-entry related injuries. CONCLUSIONS Our initial experience shows that dynamic 4D CT is useful in risk stratification prior to re-do sternotomy by determining the presence or absence of tethering between sternum and underlying structures based on assessment of differential motion. Furthermore we determined the technique to be superior to non-dynamic assessment of retrocardiac tethering.

Endothelial Denudation of Isolated Human Internal Mammary ArterySegments

Background: Endothelial denudation is an important approach to evaluate the role of the endothelium in vascular reactivity studies. Although approaches to remove the endothelium are well established in animal models, these methods have proved difficult to effectively translate to remnants of human Internal Mammary Artery (IMA) obtained during coronary bypass. This study sought to identify the optimal technique for endothelial denudation of IMA while preserving vascular contractile responses. Methods: IMA segments were subject to endothelial denudation using one of the following techniques: (1) surface abrasion, rubbing with a stainless steel wire, (2) vasoconstriction abrasion or (3) shear abrasion via infusion of an effervescent solution. Following intervention, IMA segments were evaluated by: (1) histochemistry to quantify structural damage and endothelial cell abundance and (2) functional endothelium-dependent vasodilator response using vascular myography in an organ bath preparation. Results: Vasoconstriction abrasion removed endothelial cells and caused disruption of the internal elastic lamina, these vessels failed to respond to the vasoconstrictor Phenylephrine (PE) or the endothelium-dependent vasodilator A23187. Surface abrasion alone was incomplete in removing endothelial cells, vessel vasodilated partially when challenged with A23187 in the presence of PE. Shear abrasion removed endothelial cells most effectively, as these pre-constricted vessels did not relax to A23187 but demonstrated increased sensitivity to PE. Conclusions: In this controlled comparative study assessing both structural and functional endpoints of endothelial denudation techniques, we have demonstrated that shear abrasion by infusion of an effervescent solution is the optimal technique to remove the endothelium and preserve vascular function in human IMA.