Guillermo Vaccarino

Impact of preoperative clopidogrel in off pump coronary artery bypass surgery: A propensity score analysis

OBJECTIVE The aim of our study was to evaluate the impact of recent clopidrogel use before off-pump coronary artery bypass grafting on the postoperative risk of bleeding. METHODS During the period January 2003 to December 2006, 1104 consecutive patients underwent off-pump coronary artery bypass grafting. Patients were divided into two groups according to the recent use of clopidrogel (within 7 days). We performed a propensity score to further adjust for differences between the patients with and without recent use of clopidrogel. RESULTS Mean age was 64 +/- 14 years and 87% were male. The clopidrogel group had a greater incidence of patients in unstable condition, requiring emergency coronary bypass grafting, and with a high EuroSCORE. Propensity score analysis selected 88 patients with and 176 without recent use of clopidrogel. By propensity score, the clopidrogel group had higher requirements for fresh frozen plasma units (18.1% vs 8.5%; P = .02), reoperation owing to bleeding (5.6% vs 0.5%; P = .009), and higher need for postoperative mechanical ventilation (4% vs 10%; P = .04), whereas mortality and length of stay were similar between groups. CONCLUSION Recent use of clopidogrel before off-pump coronary artery bypass grafting is associated with greater risk for bleeding with similar mortality rate.

Immediate Extubation After Off-Pump Coronary Artery Bypass Graft Surgery in 1,196 Consecutive Patients: Feasibility, Safety and Predictors of When Not To Attempt It

OBJECTIVE The purpose of this study was to evaluate the feasibility and safety of immediate extubation (ultrafast-track anesthesia [UFTA]) in the operating room, and the predictors of when not to attempt it in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB). DESIGN Case series. SETTING A private hospital. PARTICIPANTS One thousand one hundred ninety-six patients undergoing OPCAB surgery, representing 4 years of a single anesthesia services practice (3 anesthesiologists), were evaluated for immediate extubation. All patients were considered amenable to immediate extubation if specific criteria were met. INTERVENTION Patients received general anesthesia (UFTA protocol) and underwent off-pump coronary artery bypass graft surgery. MEASUREMENTS AND MAIN RESULTS One thousand sixty-five patients (89%) met extubation criteria and were extubated successfully in the operating room. By multivariate analysis, the following independent predictors of avoiding immediate extubation were identified: reoperation (odds ratio [OR] = 3.9, p < 0.001), pre-existing renal disease (OR = 3.1, p < 0.0001), diabetes (OR = 1.7, p < 0.007), preoperative intra-aortic balloon pump placement (OR = 7.4, p < 0.0001), and total surgical time (OR = 3.7, p < 0.0001). Patients who met extubation criteria had lower in-hospital reintubation (2.5% v 16%, p < 0.001), myocardial infarction (1.03% v 4.58%, p = 0.001), renal insufficiency (2.2% v 7.63%, p < 0.001), stroke (0.4% v 2.29%, p = 0.032), and mortality rates (1.2% v 10.7%, p < 0.001) than patients who did not. CONCLUSIONS UFTA is feasible and safe in most patients undergoing OPCAB surgery. Baseline and intraoperative data predicted when immediate extubation should not be attempted.

Aortic Valve Replacement in a Patient With Osler-Rendu-Weber Disease

Osler-Rendu-Weber (hereditary hemorrhagic telangiectasia) disease is an uncommon disease characterized by the presence of abnormal telangiectasias and arteriovenous malformations that cause recurrent episodes of bleeding. We present a patient with Osler-Rendu-Weber disease, with a history of multiple major bleeding events and severe aortic valve stenosis, who underwent aortic valve replacement. Unexpectedly, the postoperative course was uneventful, and there was no untoward bleeding in the early or in the late postoperative follow-up.

Pacemaker endocarditis: approach for lead extraction in endocarditis with large vegetations

The presence of large lead vegetations poses additional difficulties for explantation because many methods cannot be used due to the potential hazard of embolism. We report two patients with large vegetation on the ventricular lead due to endocarditis and one of them with an atrial septal defect associated. It was applied a combined technique of transvenous lead removal and sternotomy with cardiopulmonary bypass for the complete removal of pacemaker wires. This procedure resolved the pacemakers endocarditis safely and subsequently a new transvenous device was placed on the opposite site.

Cirurgia coronária com condutos arteriais múltiplos sem circulação extracorpórea

OBJECTIVE: To analyze intra-hospital results in patients undergoing elective off-pump total arterial revascularization and identify morbidity and mortality predictors using this surgical strategy. METHOD: From May 1999 to February 2004, 203 myocardial revascularization procedures with total arterial revascularization without cardiopulmonary bypass (off-pump) were carried out in patients with multivessel disease (three vessels 81.7 %, one vessel disease was excluded). We report pre-surgical variables and co-morbidities: average age 63.9 ± 9.13 years, men 182 (89.5%), hypertension 132 (65%), smokers 125 (61%), hypercholesterolemia 152 (74.8%), previous myocardial infarction (> 30 days) 73 (35%), moderate to severe ventricular dysfunction 31 (15%), redo five (2.5%). Total arterial revascularization included T-grafts and sequential grafts with left internal mammary (100%), right internal mammary (56.6%) and radial (63%) arteries. The total number of distal anastomosis was 576 (mean of three grafts/patient), all carried out with external mechanical stabilizers. There were no proximal aortic anastomoses. Conversion to on-pump surgery occurred in three (1.5%) patients; 90% of the patients was extubated in the operating room. The multiple logistic regression test was used for statistical analysis. RESULTS: The postoperative incidence of atrial fibrillation was 12.8% (26), oligoanuric renal failure 3% (six), dialysis 0.49% (one), postoperative myocardial infarction 1.47% (three), low cardiac output 4% (eight), Redo for bleeding 1.47% (three), mediastinitis 1.47% (three), stroke 1.47% (three). Intra-hospital mortality was 2.45% (five). The only independent 30 day morbidity predictor was age (p=0.033; OR 1.04; IC 95%: 1-1.08). CONCLUSION: Off-pump myocardial revascularization with arterial conduits for multiple vessel disease is feasible with a low 30-day morbidity and mortality.

Parasternal approach for redo in ascending aorta pseudoaneurysm

Aortic ascending pseudoaneurysm is a rare complication following aortic root surgery. The surgical solution of the complication is rather demanding and complex, especially when reaching the mediastinum. The latter translates into an elevated morbidity and mortality. We present a case performed through a minimal anterior right thoracotomy, which allowed us to dissect between the pseudoaneurysm and the internal site of the sternum as a first step prior to a second sternotomy. By using this approach, we minimized bleeding risks and the possibility of aortic rupture. This technique could have the potential to be generally applicable in this complication after further evaluation.

Loss of dystrophin is associated with increased myocardial stiffness in a model of left ventricular hypertrophy

Transition from compensated to decompensated left ventricular hypertrophy (LVH) is accompanied by functional and structural changes. Here, the aim was to evaluate dystrophin expression in murine models and human subjects with LVH by transverse aortic constriction (TAC) and aortic stenosis (AS), respectively. We determined whether doxycycline (Doxy) prevented dystrophin expression and myocardial stiffness in mice. Additionally, ventricular function recovery was evaluated in patients 1 year after surgery. Mice were subjected to TAC and monitored for 3 weeks. A second group received Doxy treatment after TAC. Patients with AS were stratified by normal left ventricular end-diastolic wall stress (LVEDWS) and high LVEDWS, and groups were compared. In mice, LVH decreased inotropism and increased myocardial stiffness associated with a dystrophin breakdown and a decreased mitochondrial O2 uptake (MitoMVO2). These alterations were attenuated by Doxy. Patients with high LVEDWS showed similar results to those observed in mice. A correlation between dystrophin and myocardial stiffness was observed in both mice and humans. Systolic function at 1 year post-surgery was only recovered in the normal-LVEDWS group. In summary, mice and humans present diastolic dysfunction associated with dystrophin degradation. The recovery of ventricular function was observed only in patients with normal LVEDWS and without dystrophin degradation. In mice, Doxy improved MitoMVO2. Based on our results it is concluded that the LVH with high LVEDWS is associated to a degradation of dystrophin and increase of myocardial stiffness. At least in a murine model these alterations were attenuated after the administration of a matrix metalloprotease inhibitor.

Influencia de diabetes mellitus y de la calidad de los lechos coronarios en el seguimiento alejado de la cirugía coronaria. Estudio «SEGUIR II»

Resumen es: Objetivo Analizar la evolucion alejada de los pacientes diabeticos (DBT) en el seguimiento a largo plazo luego de cirugia coronaria (CRM) y su relacion c...