Ivan Iglesias

Monitoring brain oxygen saturation during coronary bypass surgery: a randomized, prospective study.

BACKGROUND:Cerebral deoxygenation is associated with various adverse systemic outcomes. We hypothesized, by using the brain as an index organ, that interventions to improve cerebral oxygenation would have systemic benefits in cardiac surgical patients. METHODS:Two-hundred coronary artery bypass patients were randomized to either intraoperative cerebral regional oxygen saturation (rSO2) monitoring with active display and treatment intervention protocol (intervention, n = 100), or underwent blinded rSO2 monitoring (control, n = 100). Predefined clinical outcomes were assessed by a blinded observer. RESULTS:Significantly more patients in the control group demonstrated prolonged cerebral desaturation (P = 0.014) and longer duration in the intensive care unit (P = 0.029) versus intervention patients. There was no difference in overall incidence of adverse complications, but significantly more control patients had major organ morbidity or mortality (death, ventilation >48 h, stroke, myocardial infarction, return for re-exploration) versus intervention group patients (P = 0.048). Patients experiencing major organ morbidity or mortality had lower baseline and mean rSO2, more cerebral desaturations and longer lengths of stay in the intensive care unit and postoperative hospitalization, than patients without such complications. There was a significant (r2 = 0.29) inverse correlation between intraoperative rSO2 and duration of postoperative hospitalization in patients requiring ≥10 days postoperative length of stay. CONCLUSION:Monitoring cerebral rSO2 in coronary artery bypass patients avoids profound cerebral desaturation and is associated with significantly fewer incidences of major organ dysfunction.

Simultaneous integrated coronary artery revascularization with long-term angiographic follow-up

OBJECTIVE Traditionally integrated coronary artery revascularization has been described as a 2-stage procedure. We evaluated the safety and feasibility of 1-stage, simultaneous, hybrid, robotically assisted coronary artery bypass grafting surgery and percutaneous coronary intervention. METHODS Fifty-eight patients underwent simultaneous, integrated coronary artery revascularization in an operating theater equipped with angiographic equipment. Forty-five patients were men. The mean age was 59 years. All internal thoracic arteries were harvested with robotic assistance. All anastomoses were manually constructed through a small anterior non-rib-spreading incision without cardiopulmonary bypass on the beating heart. Immediately after and within the same operative suite, both angiographic confirmation of graft patency and percutaneous coronary intervention were performed. In 52 patients therapeutic anticoagulation was achieved with the direct thrombin inhibitor bivalirudin. RESULTS There were no deaths or wound infections. There was 1 perioperative myocardial infarction. One patient had a stroke, and 3 patients required re-exploration for bleeding. The median lengths of intensive care and hospital stay were 1 and 4 days, respectively. All patients were alive and symptom free at follow-up (mean, 20.2 months; range, 1.1-40.8 months). Long-term angiographic follow-up in 54 patients showed 49 (91%) patent grafts (mean, 9.0 months; range, 4.3-40.8 months). There were 7 in-stent restenoses and 2 occluded stents. CONCLUSION For multivessel coronary artery disease, simultaneous integrated coronary artery revascularization with bivalirudin is safe and feasible. This approach enables complete multivessel revascularization with decreased surgical trauma and postoperative morbidity. Further studies are necessary to better determine patient selection and long-term outcomes.

Comparison of isoflurane and sevoflurane in cardiac surgery: a randomized non-inferiority comparative effectiveness trial

PurposeVolatile anesthetics possess cardioprotective properties, but it is unknown if the cardioprotective effects extend equally to all members of the class. Although sevoflurane is a relatively newer anesthetic than isoflurane, its introduction into practice was not preceded by a head-to-head comparison with isoflurane in a trial focusing on clinically important outcomes. Our objective was to determine whether sevoflurane was non-inferior to isoflurane on a clinically important primary outcome in a heterogeneous group of adults undergoing cardiac surgery.MethodsThis was a pragmatic randomized non-inferiority comparative effectiveness clinical trial in 464 adults having coronary artery bypass graft and/or single valve surgery during November 2011 to March 2014. The intervention was maintenance of anesthesia with sevoflurane (n = 231) or isoflurane (n = 233) administered at a dose of 0.5-2.0 MAC throughout the entire operation. All caregivers were blinded except for the anesthesiologist and perfusionist. The primary outcome was a composite of intensive care unit (ICU) length of stay ≥ 48 hr and all-cause 30-day mortality. We hypothesized that sevoflurane would be non-inferior to isoflurane (non-inferiority margin < 10% based on an expected event rate of 25%). Secondary outcomes included prolonged ICU stay, 30- and 365-day all-cause mortality, inotrope or vasopressor usage, new-onset hemodialysis or atrial fibrillation, stroke, and readmission to the ICU.ResultsNo losses to follow-up occurred. The primary outcome occurred in 25% of sevoflurane patients and 30% of isoflurane patients (absolute difference, −5.4%; one-sided 95% confidence interval, 1.4), thus non-inferiority was declared. Sevoflurane was not superior to isoflurane for the primary outcome (P = 0.21) or for any secondary outcomes.ConclusionSevoflurane is non-inferior to isoflurane on a composite outcome of prolonged ICU stay and all-cause 30-day mortality. Sevoflurane is not superior to isoflurane on any other of the clinically important outcomes. This trial was registered at clinicaltrials.gov; NCT01477151.RésuméObjectifLes agents anesthésiques volatils possèdent des propriétés cardioprotectrices, mais nous ne savons pas si ces effets cardioprotecteurs sont équivalents pour tous les agents de cette classe. Bien que le sévoflurane soit un anesthésique plus récent que l’isoflurane, son introduction dans notre pratique n’a pas été précédée par une comparaison directe à l’isoflurane dans une étude s’intéressant à d’importants critères d’évaluation cliniques. Notre objectif était de déterminer si le sévoflurane était non inférieur à l’isoflurane en relation à un critère d’évaluation principal important d’un point de vue clinique dans un groupe hétérogène d’adultes subissant une chirurgie cardiaque.MéthodeNous avons réalisé une étude clinique randomisée et pragmatique d’efficacité comparative et de non-infériorité auprès de 464 adultes subissant des pontages coronariens et/ou une chirurgie valvulaire unique entre novembre 2011 et mars 2014. L’intervention consistait en le maintien de l’anesthésie à l’aide de sévoflurane (n = 231) ou d’isoflurane (n = 233) administré à une dose de 0,5-2,0 MAC tout au long de l’opération. Aucun intervenant ne connaissait l’agent utilisé, à l’exception de l’anesthésiologiste et du perfusionniste. Le critère d’évaluation principal était une composée de la durée de séjour à l’unité de soins intensifs (USI) ≥ 48 h et de la mortalité, toutes causes confondues, à 30 jours. Nous avons émis l’hypothèse que le sévoflurane ne serait pas inférieur à l’isoflurane (marge de non-infériorité < 10 % sur la base d’un taux de complications attendu de 25 %). Les critères d’évaluation secondaires comprenaient un séjour prolongé à l’USI, la mortalité toutes causes confondues à 30 et à 365 jours, l’utilisation d’inotropes ou de vasopresseurs, une hémodialyse ou une fibrillation auriculaire nouvelles, un accident vasculaire cérébral et une réadmission à l’USI.RésultatsNous n’avons perdu aucun patient au suivi. Le critère d’évaluation principal est survenu chez 25 % des patients ayant reçu du sévoflurane et 30 % des patients ayant reçu de l’isoflurane (différence absolue, −5,4 %; intervalle de confiance unilatéral 95 %, 1,4): la non-infériorité a donc été déclarée. Le sévoflurane n’était pas supérieur à l’isoflurane en ce qui touchait au critère d’évaluation principal (P = 0,21) ou aux critères d’évaluation secondaires.ConclusionLe sévoflurane n’est pas inférieur à l’isoflurane selon un critère d’évaluation composé d’une durée de séjour prolongée à l’USI et de la mortalité toutes causes confondues à 30 jours. Le sévoflurane n’est pas supérieur à l’isoflurane en ce qui touche à n’importe quel autre critère clinique important. Cette étude a été enregistrée au ClinicalTrials.gov, numéro NCT01477151.

Intraoperative echocardiography: support for decision making in cardiac surgery.

Intraoperative echocardiography (including transesophageal echocardiography, epiaortic ultrasound and epicardial echocardiography) is commonly performed in North American hospitals during cardiac anesthesia. Several authors have reported on the positive impact of intraoperative echocardiography on patients’ outcomes. Transesophageal echocardiography is useful in identifying anatomic and functional abnormalities either before or after cardiopulmonary bypass and helps to make decisions in the care of high-risk and unstable patients. In minimally invasive and robotically assisted surgery, transesophageal echocardiography is essential in order to guide cannulation of venous and arterial vessels for cardiopulmonary bypass and in providing immediate assessment of the quality of the performed repair. Intraoperative echocardiography can also detect complications associated with the performed procedure and can be an excellent hemodynamic monitor in unstable patients. In this paper different scenarios where intraoperative echocardiography is useful are reviewed, some clinical cases are shown to illustrate, and a review of related literature is reported.

Intraoperative TEE Assessment During Mitral Valve Repair for Degenerative and Ischemic Mitral Valve Regurgitation

Intraoperative assessment of the mitral valve (MV) in patients undergoing repair for MV regurgitation is a valuable support for the cardiac surgical team; results can be favored by adequate assessment tailored to the main condition affecting the MV. This article will review current available data for assessment of the MV in degenerative and ischemic mitral regurgitation.

Is the Future of Coronary Arterial Revascularization a Hybrid Approach?: The Canadian Experience Across Three Centers.

Objective Hybrid coronary revascularization offers and combines the advantages of both surgical and percutaneous revascularization and eliminates at the same time the disadvantages of both procedures. The objective of this study was to assess graft and stent patency at 6 months, rate of bleeding, intensive care unit and hospital stay, rate of reintervention, and long-term clinical follow-up. Methods From March 2004 to November 2015, a total of 203 patients underwent robotic-assisted minimally invasive direct coronary artery bypass graft of the left internal thoracic artery to the left anterior descending artery and PCI of a non-left anterior descending vessel in a single or two stage, at three different centers. Patients underwent 6-month angiographic follow-up. The mean ± SD clinical follow-up was 77.82 ±41.4 months. Results Successful hybrid coronary revascularization occurred in 196 of the 203 patients. One hundred forty-six patients underwent simultaneous surgical and percutaneous intervention. Nineteen patients underwent PCI before surgery, and 38 patient underwent PCI after surgery. No in-hospital mortality occurred. The mean ± SD ICU stay was 1 ± 1 days and the mean ± SD hospital stay was 5 ± 2 days. Only 13.3% of the patients required a blood transfusion. Six-month angiographic follow-up has been performed in the 95 patients, and it demonstrated a left internal thoracic artery anastomotic patency of 97.9% and stent patency of 92.6%. A total of 77.8 ± 41.4-month clinical follow-up demonstrated 95.1% survival, 92.6% freedom from angina, and 90.7% freedom from any form of coronary revascularization. Conclusions Hybrid coronary revascularization seems to be a promising and safe revascularization strategy. It provides selected patients with an alternative, functionally complete revascularization with minimal surgical trauma and good long-term clinical outcomes.

Robotic-assisted left atrial ligation for stroke reduction in chronic atrial fibrillation: a case report.

Patients with atrial fibrillation are at significant risk for sustaining a thromboembolic stroke. More than 90% of thromboemboli form in the left atrial appendage. Ligation of the left atrial appendage to reduce the risk of stroke is often performed in connection with other cardiac surgical procedures. As a stand-alone procedure, however, left atrial ligation has generally been deemed too invasive and has gained little support as an alternative therapeutic option. We report a case of port-access robotic-assisted left atrial ligation as a stand-alone procedure in a patient with chronic atrial fibrillation in whom anticoagulation was a contraindication. To our knowledge, this is the first reported case of stand-alone robotic-assisted left atrial ligation in the literature.

Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization

Objective Contemporary anesthetic techniques have enabled shorter sedation and early extubation in off-pump and minimally invasive coronary artery bypass (CABG) surgery. Robotic-assisted CABG represents the optimal surgical approach for ultrafast track anesthesia, with patients able to bypass the cardiac surgical intensive care unit with recovery in the postanesthesia care unit (PACU) and inpatient ward. Methods In-hospital postoperative outcomes from ninety patients who underwent either elective or urgent robotically-assisted CABG at our institution were reviewed. These patients were carefully selected by a multidisciplinary team to undergo fast-track anesthesia: extubation in the operating room, 4-hour recovery in the postanesthesia care unit and transfer to the inpatient ward. Intrathecal, paravertebral local, and patient-controlled anesthesia techniques were used to facilitate transition to oral analgesics. Results Average patient age was 61 ± 9 years. Sixty-six patients (73%) were male. Seventy cases were elective, and 20 patients required urgent revascularization. All patients underwent intraoperative angiography after graft construction, which revealed Fitzgibbon class A grafts. There were no in-hospital mortalities. One patient required re-exploration for bleeding, through the same minimally invasive incision, did not require conversion to sternotomy for bleeding, and was transferred to the intensive care unit postexploration for bleeding for standard postoperative care. Postoperative complications were limited to one superficial wound infection. The mean hospital length of stay was 3.5 ± 1.17 days. Conclusions In patients undergoing robotic-assisted CABG, ultrafasttrack cardiac surgery with immediate postprocedure extubation and transfer to the inpatient ward has been demonstrated to be safe with no increase in perioperative morbidity or mortality. It requires a dedicated heart team with a carefully selected group of patients. Avoiding cardiac surgical intensive care unit expedites recovery, with possible avoidance of infection and early discharge from hospital.

Robotic coronary artery bypass surgery in a patient with haemophilia A

M. GERMAN,* L. MINUK,† C. ADAMS,* P. DIAMANTOUROS,‡ I . IGLESIAS,§ P. M JONES§ and B. KIAII* *Division of Cardiac Surgery, Department of Surgery, London Health Sciences Centre, Western University; †Division of Hematology, London Health Sciences Centre, Western University; ‡Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University; and §Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada

Transventricular Crushing and Extrication of Embolized Transcatheter Aortic Valve Prosthesis

Transventricular Crushing and Extrication of Embolized Transcatheter Aortic Valve Prosthesis Christopher Tarola, MD, Bob Kiaii, MD, FRCSC, Patrick Teefy, MD, FRCPC, Pantelis Diamantorous, MD, FRCPC, Daniel Bainbridge, MD, FRCPC, Philip M. Jones, MD, FRCPC, Ivan Iglesias, MD, FRCPC, and Michael W. A. Chu, MD, FRCSC Division of Cardiac Surgery, Western University, London, Ontario, Canada Division of Cardiology, Western University, London, Ontario, Canada Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada