Franco Sogliani

The impact of major perioperative renal insult on long-term renal function and survival after cardiac surgery

Temporary renal replacement therapy (RRT) facilitates recovery from a major perioperative renal injury and, although RRT can improve the hospital outcome, it is not known as to whether it mitigates long-term renal sequelae. Therefore, we investigated the risk of long-term dialysis after RRT post-cardiac surgery. We analysed prospectively the data collected for all hospital survivors who received RRT following cardiac surgery between March 1996 and July 2010, excluding those on dialysis preoperatively or with a functioning renal transplant. The follow-up data were obtained for all surviving patients. The mean age of the 82 patients was 68.6 ± 9.9 years, and 60 (73%) were male. Severe pre-existing renal dysfunction with a serum creatinine level of >200 μmol/l was present in 15 (18%) patients and diabetes in 31 (38%) patients. Operative procedures included redo surgery (n = 11, 13%) and thoracic aortic surgery (n = 9, 11%). During a 13.4-year follow-up, there were 38 late deaths. Only three patients with severe preoperative renal dysfunction received dialysis. The Kaplan-Meier 5- and 7-year survival rates for this patient cohort were 54% and 38%, respectively. In conclusion, a major renal insult requiring temporary RRT after cardiac surgery does not increase the risk for renal dialysis in the long term for patients with normal renal function preoperatively.

Early and late prognostic implications of coronary artery bypass timing after myocardial infarction.

OBJECTIVES The optimal timing of coronary artery bypass grafting (CABG) after myocardial infarction (MI) is still controversial. With advances in perioperative care and myocardial protection, CABG is not infrequently undertaken sooner. Although CABG soon after MI is associated with high morbidity and mortality, the impact of CABG timing on late survival is not clear. METHODS We analysed prospectively collected data for 8320 patients who underwent primary CABG from 1996 through 2010. Operative outcomes and late survival were compared between patient categories based on MI-to-CABG days: groups A (0-30, n = 658), B (31-60, n = 734), C (>90, n = 2698) and D (no MI, n = 4230). The effect of the timing of surgery on survival was determined using multivariate and Kaplan-Meier analyses. RESULTS As the MI-to-CABG interval increased, the frequency of urgent/emergency operations decreased and hospital mortality (A, 3.5% vs B, 2.6% vs C, 1.2%, vs D, 1.1%, P < 0.0001) steadily declined. In general, patients who had CABG within 90 days of MI had more cardiac morbidity and co-morbidities. Expectedly, therefore, postoperative organ system dysfunction (cardiac, renal, respiratory and neurological) was more frequent in these groups. Reoperation for bleeding was similar for all groups, but blood product transfusion decreased as the MI-to-CABG days increased. The 10-year survival improved with the MI-to-CABG interval (A, 72.2% vs B, 73.4% vs C, 75.8% vs D, 81.4%, P < 0.0001). By multivariate analysis, the MI-to-CABG interval was not a risk factor for operative or late mortality. However, less frequent were left internal mammary artery use, non-elective surgery and high blood transfusion rates; all more often associated with shorter MI-to-CABG intervals. CONCLUSIONS Early and late mortality risk for CABG declines with increasing interval from MI for reasons indirectly linked to the timing of surgery. Our findings emphasize the importance of preoperative organ system optimization and consistent left internal mammary artery use, regardless of the proximity of surgery to MI or the exigency of surgery.

Guide wire thrombus formation during trans-femoral TAVI.

The Amplatz super-stiff (SS) guidewire (Boston Scientific, MA, USA) is commonly used and routinely modified in shape during TAVI. The intention is to form a ‘curvature’ at the 3.5 cm flexible tip to reduce the risk of left ventricular myocardial perforation during catheter manipulations and valve delivery. We report 2 cases of distal guide wire thrombus formation that occurred on areas of the wire that had been manipulated in shape (Figs. 1 and 2). Both were visualised by intraprocedure TOE and occurred despite an activated clotting time (ACT) greater than 300 seconds prior to wire placement, pre-treatment with dual anti-platelet therapy (aspirin and clopidogrel 75 mg daily) and regular aspiration/flushing of the 18 Fr introducer sheath. Both patients had extensive other co-morbidities, including significant left ventricular systolic dysfunction, and had both been declined surgical aortic valve replacement. The sequence of our trans-femoral TAVI is consistent -we introduce the18Fr sheath over the SSwire placed in the thoracic aorta, then remove the SSwire,flush the 18Fr sheath side arm and then cross the aortic valve with a catheter (usually AL1), exchange for a pigtail catheter and thenposition the SSwire through the pigtail catheter (with careful live TOE to check the wire position).

A surgical strategy for cor triatriatum atrial septal defect--A1 lam subclass.

Atrial fibrillation and a heart murmur were diagnosed in a 68-year-old woman during a routine medical examination. She presented 2 years later with pulmonary edema. A transthoracic echocardiography examination revealed a tunneled atrial septal defect (ASD) and severe tricuspid regurgitation. Transesophageal echocardiography and 3-dimensional computed tomography evaluations revealed multiple intracardiac defects, including abnormal atrial septation suggestive of a typical cor triatriatum sinistrum (A1 Lam subclass), a rare congenital defect in adults. The patient underwent tricuspid valve repair with concomitant closure of the ASD by using the cor triatriatum curtain to form an autologous transposition flap. The intraoperative transesophageal and predischarge imaging evaluations confirmed an excellent repair. The patient made a swift recovery and demonstrated improvement in her symptoms at follow-up. This previously undescribed technique eliminates the need for a prosthetic implant and is applicable in >80% of cor triatriatum cases in which an ASD exists.

Non-Hodgkins lymphoma in a patient with tracheal bronchus who presented with atypical pneumonia: a diagnostic dilemma.

A 47-year-old unemployed man presented with a 2-week history of shortness of breath, dry cough and fever despite normal inflammatory markers and negative blood cultures. There was no weight loss or night sweats. He was a non-smoker and had no other medical history. HIV testing and tumour markers were negative. Chest x-ray (figure 1A) showed what seemed to be a dense consolidation in the right mid-zone and lower zone. This was confirmed on CT (figure 1F), so wedge biopsies of the right middle and right lower lobes were taken via video-assisted thoracoscopy (VATS). There were no palpable lymph nodes and no evidence of significant mediastinal …

Contained aortic rupture as a late complication of transcutaneous aortic valve implantation.

Transcutaneous aortic valve implantation (TAVI) is an effective treatment strategy for aortic stenosis in patients deemed unfit for conventional surgery ([1][1]). Various complications of TAVI have been reported ([2–4][2]); however, aortic rupture leading to hematoma formation acting as a source