Hugh Wolfenden

Ultra-low dose aprotinin decreases transfusion requirements and is cost effective in coronary operations

BACKGROUND The recommended dose of aprotinin has been shown to reduce blood loss and need for blood transfusions, but the cost precludes its routine use. This study was designed to determine whether a less expensive, ultra-low dose of aprotinin is effective when used in coronary artery bypass grafting with left internal mammary artery. METHODS Patients (n = 202) were randomized to receive either placebo or aprotinin, 0.5 million KIU before incision and 0.5 million KIU during initiation of cardiopulmonary bypass. Differences in quantity of blood transfused were analyzed. Further groups were analyzed to account for the effect of aspirin. Multivariable analysis was performed to determine risk factors for transfusion. Direct costs of blood products and aprotinin were tabulated for each group. RESULTS There was an important reduction in the proportion of patients transfused, and number of blood units transfused when aprotinin was given before coronary artery bypass grafting. These differences were even more important in patients on aspirin preoperatively. Independent predictors for increased number of transfusions were aspirin continued before operation, smaller body surface area, and the use of placebo instead of ultra-low dose aprotinin. There was no difference in morbidity between treatment groups. There was a reduction in direct costs associated with the use of aprotinin. CONCLUSIONS These data support the routine use of aprotinin 1 million KIU in coronary artery bypass grafting with left internal mammary artery to reduce cost and transfusion requirements.

Combined coronary artery bypass grafting and excision of adrenal pheochromocytoma

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Giant right atrium in an adult: case report of a rare condition.

We report one of the largest descriptions of the right atrium (RA) in an adult, in absence of Ebsteins anomaly, tricuspid stenosis and other common adult associations of RA enlargement, such as pulmonary hypertension secondary to chronic pulmonary disease or severe mitral valvular pathology and pulmonary embolism. The RA volume was estimated to be over 1400 ml and was notably disproportionate to that of the left atrium and either ventricle.

Outcomes of cardiac surgery in chronic kidney disease

OBJECTIVE To identify predictors of early and late outcomes of cardiac surgery in patients with chronic kidney disease. METHODS Patients (n=545) with serum creatinine≥200 μmol/L or renal dialysis were identified from databases maintained by the largest Sydney cardiothoracic surgical units with data consistent with the Australian and New Zealand Society of Cardiothoracic Surgeons data definitions. The patient data were matched against the National Dialysis Database and the New South Wales Register of Births, Deaths, and Marriages. Statistical analysis was used to identify predictors of early and late outcomes. RESULTS The Kaplan-Meier estimate of 1-, 5-, and 10-year survival for all patients was 78%, 56%, and 36%, respectively. The outcomes were similar after coronary bypass surgery and valve replacement and were also similar for dialysis and nondialysis patients. The odds ratios for the significant independent predictors of outcomes were, for perioperative death, age (1.4 per decade), emergency surgery (7.0), redo surgery (3.8), left ventricular impairment (moderate, 2.7; severe, 4.4); for new early postoperative dialysis, estimated glomerular filtration rate<20 mL/min (3.8), emergency surgery (2.7), tricuspid valve surgery (4.4); for new permanent dialysis within 6 months of surgery, serum estimated glomerular filtration rate<20 mL/min (odds ratio, 4.6). The hazard ratio for the independent predictors of late death in those alive 6 months after surgery was 1.4 per decade for age and 1.4 for moderate or severe left ventricular impairment. CONCLUSIONS Left ventricular impairment is a risk factor for perioperative and late death in patients with kidney disease. After cardiac surgery, preoperative dialysis-dependent and dialysis-free patients had similar long-term outcomes.

Recurrent ischaemic mitral regurgitation post mitral annuloplasty due to suture dehiscence evaluated using real time three dimensional transoesophageal echocardiography.

Ischaemic mitral regurgitation after myocardial infarction results from geometric changes in left ventricular shape and displacement of papillary muscles with resultant tethering and incomplete leaflet coaptation of mitral leaflets. Post mitral valve repair, both valve apparatus related factors such as persistent leaflet tethering and progressive left ventricular adverse remodelling and procedure related factors such as ring dehiscence are important causes of recurrent mitral regurgitation after initial undersized mitral ring annuloplasty. Three-dimensional echocardiography is a novel clinical tool that has the potential to provide additional anatomical and functional information regarding the mechanism of recurrent mitral regurgitation post mitral valve repair that is complementary to standard two dimensional transoesophageal echocardiography thus helping guide the most appropriate subsequent therapeutic intervention.

Mitral valve surgery and coronary artery bypass grafting for moderate-to-severe ischemic mitral regurgitation: Meta-analysis of clinical and echocardiographic outcomes

Objective: This meta‐analysis was conducted to compare clinical and echocardiographic outcomes following isolated coronary artery bypass grafting (CABG) versus CABG and mitral valve (MV) surgery in patients with moderate‐to‐severe ischemic mitral regurgitation (IMR). Methods: Seven databases were systematically searched to identify relevant studies. For eligibility, studies were required to report on the primary endpoint of perioperative or late mortality. Data were analyzed according to predefined clinical endpoints. Results: Four randomized controlled trials (RCTs) (n = 505) and 15 observational studies (OS) (n = 3785) met the criteria for inclusion. Compared with isolated CABG, concomitant CABG and MV surgery was not associated with increased perioperative mortality (RCTs: relative risk [RR] 0.89, 95% confidence interval [CI], 0.26–3.02; OS: RR 1.40, 95% CI, 0.88–2.23). CABG and MV surgery was associated with significantly lower incidence of moderate‐to‐severe MR at follow‐up (RCTs: RR 0.16, 95% CI, 0.04–0.75; OS: RR 0.20, 95% CI, 0.09–0.48). Late mortality was similar between the surgical approaches in RCTs (hazard ratio [HR] 1.20, 95% CI, 0.57–2.53) and OS (HR 0.99, 95% CI, 0.81–1.21). There were no significant differences in echocardiographic outcomes. These results remained consistent in subgroup analyses restricted to patients with strictly moderate IMR. Conclusions: In patients with moderate‐to‐severe IMR, the addition of MV surgery to CABG was not associated with increased perioperative mortality. Although concomitant MV surgery reduced recurrence of moderate‐to‐severe MR at follow‐up, this was not associated with a reduction in late mortality. Larger trials with longer follow‐up duration are required to further assess long‐term survival and freedom from reintervention.

Functional mitral valve regurgitation: repair or replacement?

rimary mitral valve disease involves damage to leaflet or chordal tissue, whereas functional P (or secondary) mitral regurgitation (MR) typically involves a combination of mitral annular dilatation and leaflet restriction caused by ventricular dysfunction in patients with normal leaflets and chordae. Assessing the severity of regurgitation in secondary MR is more difficult than in primary MR, as the regurgitant orifice area is often underestimated by echocardiography because of its crescent shape during systole. Left ventricular stroke volume is usually reduced in secondary MR, so that lesser degrees of regurgitant volume are more significant.

Operative Outcomes with Myxomatous Mitral Valve Repair: Experience with 586 Patients

INTRODUCTION American Heart Association (AHA) guidelines recommend mitral valve repair for myxomatous mitral regurgitation whenever possible to prevent LV dysfunction and early mortality. Here we review our early operative outcomes with mitral valve repair for myxomatous mitral regurgitation. METHODS We collected data from 586 consecutive patients that underwent mitral repair for myxomatous disease at the Prince Henry and Prince of Wales Hospitals Sydney between 1997 and 2012. All patients had pre- and postoperative transthoracic echocardiograms. RESULTS In the first 30 days postoperatively there were five deaths (0.9%), four strokes (0.7%) and five transient ischaemic attacks (TIAs) (0.9%). Repair involved resection in 55.5%, neochordal reconstruction in 41.6%, and in 2.9% a combination of both. There was increasing use of neochordae since 2006. At discharge 99% had mitral regurgitation (MR) ≤ mild and ≤ trivial in 79.5%. For posterior leaflet disease neochordae had improved MR at discharge compared with resection (85% vs 78%, P<0.05). Preoperative triscupid regurgitation (TR) and pulmonary hypertension > mild were associated with a greater degree of MR at discharge (P<0.05) for reasons that are unclear. CONCLUSION We have shown excellent early results for mitral repair with very low operative mortality and excellent freedom from significant MR. Successful mitral repairs with low morbidity have resulted in a pattern of early referral in keeping with the current guidelines.

A National Cardiac Surgery Database: why, how and when?

As users of large amounts of public funding, surgeons are increasingly being required to justify their activities. The provision of accurate risk-stratified data on cardiac surgical procedures and their outcomes allows for government review while also providing a means of achieving potential improvements to strategies for the management of higher risk patients. In addition, accurate data will allow for the appropriate assessment of results that fall outside acceptable benchmark standards. A management strategy may then be implemented, following peer-review processes, to examine the outlying results on an anonymous basis. The dataset currently employed in the Victorian Database is derived from USA and UK models, and it will be used for the development of a national database. This project has Federal Government support in principle, and, it is hoped, its eventual financial backing.