Jacek Karski

Non-steroidal anti-inflammatory drugs in treatment of postoperative pain after cardiac surgery

Purpose: Non-steroidal anti-inflammatory drugs (NSAIDs) are used as analgesic in postoperative pain to reduce opioid side effects, such as drowsiness and nausea. However, NSAIDs have not been used extensively in cardiac surgical patients due to the fear of untoward effects on gastric, renal, and coagulation parameters. This study will evaluate the efficacy and safety of three NSAIDs for pain control in CABG patients.Methods: One hundred and twenty patients scheduled for elective CABG surgery were enrolled in randomized, double blind, controlled study. Standardized fast track cardiac anesthesia was used. One dose of drug (75 mg diclofenac, 100 mg ketoprofen, 100 mg indomethacin, or placebo) was givenpr one hour before tracheal extubation and a second dose 12 hr later. Pain was treated with morphineiv and acetaminophenpo. Visual analogue pain scores were recorded at baseline, 3, 6, 12 and 24 hr after the first dose of drug.Results: There were no differences among the groups in pain scores. Only patients who received diclofenac required less morphine than patients in the control group (P<0.05). When the total amounts of pain medications were computed to morphine equivalents, only patients in the diclofenac group received less pain medications than the placebo group (P<0.05). Proportion of patients with postoperative increase of creatinine level (20% and over) did not differ between placebo and drug groups.Conclusion: Non-steroidal anti-inflammatory drugs may be used for anaalgesia management post CABG surgery in selected patients. Diclofenac appears to have the best analgesic effects by reducing the morphine and other analgesic requirement postoperatively.RésuméObjectif: Les anti-inflammatoires non stéroïdiens (AINS) servent d’analgésique postopératoire et réduisent les effets secondaires des opioïdes, comme la somnolence et les nausées. Leur emploi en cardiochirurgie est plutôt restreint où on craint des effets gastriques et rénaux indésirables et des modifications de la coagulation. On a voulu évaluer l’efficacité et la sécurité d’emploi analgésique de trois AINS chez des patients qui subissent un pontage aortocoronarien.Méthode: L’étude randomisée, contrôlée et à double insu a porté sur 120 patients qui devaient subir un pontage aortocoronarien. Une anesthésie cardiaque normalisée pour un séjour hospitalier écourté a été utilisée. Une dose de médicament (75 mg de diclofénac, 100 mg de kétoprofène, 100 mg d’indométhacine, ou un placebo) a été administréepr une heure avant l’extubation endotrachéale et une seconde dose 12 h plus tard. La douleur a été traitée avec de la morphineiv et de l’acétaminophènepo. Les scores de douleur ont été enregistrés à l’échelle visuelle analogique au début, puis 3, 6, 12 et 24 h après la première dose de médicament.Résultats: Les scores de douleur n’ont pas présenté de différence intergroupe. Seuls les patients du groupe diclofénac ont demandé moins de morphine que ceux du groupe témoin (P<0,05). Lorsque les quantités totales d’analgésiques ont été calculées en équivalents de morphine, seuls les patients du groupe diclofénac avaient reçu moins d’analgésique que les témoins (P<0,05). La proportion de patients qui présentaient une augmentation postopératoire du niveau de créatinine (20 % et plus) ne différait pas du groupe placebo aux autres groupes.Conclusion: Les anti-inflammatoires non stéroïdiens sont utiles en analgésique postopératoire chez des patients qui subissent un pontage aortocoronarien planifié. Le diclofénac semble offrir la meilleure analgésie en réduisant les besoins de morphine et d’autres analgésiques.

Quantification of Mitral Valve Anatomy by Three-Dimensional Transesophageal Echocardiography in Mitral Valve Prolapse Predicts Surgical Anatomy and the Complexity of Mitral Valve Repair

BACKGROUNDnThree-dimensional (3D) transesophageal echocardiography (TEE) is more accurate than two-dimensional (2D) TEE in the qualitative assessment of mitral valve (MV) prolapse (MVP). However, the accuracy of 3D TEE in quantifying MV anatomy is less well studied, and its clinical relevance for MV repair is unknown.nnnMETHODSnThe number of prolapsed segments, leaflet heights, and annular dimensions were assessed using 2D and 3D TEE and compared with surgical measurements in 50 patients (mean age, 61 ± 11 years) who underwent MV repair for mainly advanced MVP.nnnRESULTSnThree-dimensional TEE was more accurate (92%-100%) than 2D TEE (80%-96%) in identifying prolapsed segments. Three-dimensional TEE and intraoperative measurements of leaflet height did not differ significantly, while 2D TEE significantly overestimated the height of the posterior segment P1 and the anterior segment A2. Three-dimensional TEE quantitative MV measurements were related to surgical technique: patients with more complex MVP (one vs two to four vs five or more prolapsed segments) showed progressive enlargement of annular anteroposterior (31 ± 5 vs 34 ± 4 vs 37 ± 6 mm, respectively, P = .02) and commissural diameters (40 ± 6 vs 44 ± 5 vs 50 ± 10 mm, respectively, P = .04) and needed increasingly complex MV repair with larger annuloplasty bands (60 ± 13 vs 67 ± 9 vs 72 ± 10 mm, P = .02) and more neochordae (7 ± 3 vs 12 ± 5 vs 26 ± 6, P < .01).nnnCONCLUSIONSnMeasurements of MV anatomy on 3D TEE are accurate compared with surgical measurements. Quantitative MV characteristics, as assessed by 3D TEE, determined the complexity of MV repair.

Assessment of mitral valve prolapse by 3D TEE angled views are key.

ASSESSMENT OF MITRAL VALVE ANATOMY by real-time 3-dimensional (3D) transesophageal echocardiography (TEE) has proven to be superior compared to 2-dimensional TEE ([1,2][1]). The standard modalities of real-time 3D TEE have recently been described ([3][2]). Demonstration of the mitral valve as seen

Early benefit of preserved cognitive function is not sustained at one-year after cardiac surgery: a longitudinal follow-up of the randomized controlled trial

PurposeRecently, we showed that processing of shed blood with a continuous-flow cell saver during cardiopulmonary bypass resulted in a clinically significant reduction in postoperative cognitive decline (POCD) six weeks after coronary artery bypass graft (CABG) surgery. The current study examined if the early benefit of reduced POCD was sustained in the same patient population at one-year follow-up.MethodsOne hundred seventy patients (cell saver group, nxa0=xa084; controls, nxa0=xa086) underwent neuropsychological testing at baseline and one year after surgery. The raw scores for each test were converted to Z-scores, and a combined Z-score of ten main variables was then calculated for each study group.ResultsPostoperative cognitive decline was present in 16 of 84 (19%) patients in the cell saver group (95% confidence interval [CI], 10.8 to 27.2) vs 15 of 86 (17.4%) patients in the control group (95% CI, 9.6 to 25.2) (Pxa0=xa00.786). Six of the 15 patients in the control group with POCD at six weeks had the impairment at one year and five did not; four were lost to follow-up. Three of the six cell saver patients with POCD at six weeks still had impairment at one year, two did not, and one was not tested. Thirteen (15.4%) and nine (10.5%) patients in the cell saver and control groups, respectively, developed new POCD which was not evident at the six-week follow-up.ConclusionsThe short-term preservation of cognitive function in elderly patients using the cell saver management strategy did not translate into a long-term benefit one year after CABG surgery. The presence of progressing cerebrovascular disease may be responsible for the long-term cognitive decline. (ClinicalTrials.gov number, NCT00193999).RésuméObjectifNous avons récemment montré que la récupération du sang avec un autotransfuseur à débit continu au cours de la circulation extracorporelle aboutissait à une réduction significative de déclin cognitif postopératoire (POCD) six semaines après une intervention chirurgicale pour pontage coronarien. L’étude actuelle a voulu savoir si l’avantage précoce d’une diminution de POCD se maintenait dans la même population après un an de suivi.MéthodesCent soixante-dix patients (groupe autotransfuseur, nxa0=xa084; groupe contrôle, nxa0=xa086) ont passé des tests neuropsychologiques avant la chirurgie et un an après. Les résultats bruts de chaque test ont été convertis en écarts réduits et un écart réduit combiné des dix principales variables a alors été calculé pour chaque groupe de l’étude.RésultatsLe déclin cognitif postopératoire était présent chez 16xa0patients sur 84 (19xa0%) dans le groupe autotransfuseur (intervalle de confiance [IC] à 95xa0%: 10,8 à 27,2) contre 15xa0patients sur 86 (17,4xa0%) dans le groupe témoin (IC à 95xa0%: 9,6 à 25,2) (Pxa0=xa00,786). Six patients parmi les 15 du groupe contrôle présentant un POCD à 6xa0semaines avaient des fonctions altérées à un an tandis que cinq n’en avaient pas lors du suivi; quatre patients ont été perdus de vue. Trois des six patients du groupe autotransfuseur présentant un POCD à 6xa0semaines avaient encore une altération des fonctions cognitives à un an tandis que deux n’en avaient plus et qu’un patient n’a pas été testé. Treize (15,4xa0%) et neuf (10,5xa0%) patients, respectivement du groupe autotransfuseur et du groupe témoin ont développé un nouveau POCD qui n’apparaissait pas lors du suivi à 6 semaines.ConclusionsLa préservation à court terme des fonctions cognitives chez des patients âgés avec l’utilisation d’une stratégie d’autotransfusion ne s’est pas traduite par un avantage à long terme, un an après chirurgie pour pontage coronarien. L’existence d’une maladie cérébrovasculaire évolutive peut être la cause du déclin cognitif à long terme. (Numéro ClinicalTrials.gov: NCT00193999).

The Effect of Nasogastric Tube Application During Cardiac Surgery on Postoperative Nausea and Vomiting—A Randomized Trial

OBJECTIVEnPostoperative nausea and vomiting (PONV) are significant morbidities following cardiac surgery. The purpose of this study was to determine if application of a nasogastric (NG) tube during cardiac surgery can reduce the prevalence of postoperative PONV.nnnDESIGNnThis study was a prospective randomized controlled trial.nnnSETTINGnUniversity tertiary referral center.nnnPARTICIPANTSnTwo hundred two patients undergoing elective cardiac procedures.nnnINTERVENTIONSnPatients were prospectively enrolled and randomized to either receive or not receive an NG tube after induction of anesthesia. Standard anesthetic technique and postoperative care were employed in all patients. Preoperative demographic data, pain score, nausea score and incidence of vomiting were recorded early (0-8 hours) and late (8-16 hours) following extubation. Antiemetic and analgesic medications were compared between the 2 groups.nnnMEASUREMENTS AND MAIN RESULTSnOne hundred three patients were randomized to no an NG tube (controls) and 99 received an NG tube as part of their perioperative management. Demographic data and surgical characteristics were similar between the 2 groups. However, the control group had more smokers. Incidence and severity of nausea, pain scores, and analgesic requirements were similar between the 2 groups. Prevalence of vomiting was more frequent in the control group (24%) than in the NG tube group (10%, p = 0.007), and was more frequent in patients who underwent valve and redo procedures.nnnCONCLUSIONSnUse of an NG tube during cardiac surgery may reduce the incidence of postoperative vomiting.

Successful off-pump pericardiectomy and coronary artery bypass in liver cirrhosis.

Abstractu2003 Cardiopulmonary bypass can be detrimental to patients with hepatic cirrhosis. Pericardiectomy performed on the beating heart is an effective treatment for pericardial constriction. Off‐pump coronary artery bypass grafting is becoming firmly established as a surgical option for myocardial ischemia associated with multivessel disease. A single‐stage operation combining both procedures without utilizing cardiopulmonary bypass has not been reported. This provided excellent surgical outcome for a patient with the dual pathology and coexisting liver cirrhosis. The off‐pump approach should be considered in such a high‐risk scenario.

External compression of superior vena cava after the replacement of ascending aorta

We present a rare complication after open-heart surgery resulting in compression of the superior vena cava (SVC) with the concurrent findings of the hypertrophic obstructive cardiomyopathy physiology. A 59-year-old woman developed a low cardiac output syndrome, persistent hypotension, and increasing filling pressures after emergency replacement of the ascending aorta and resuspension of the aortic valve due to a type A aortic dissection. Transesophageal echocardiography (TEE) evaluation revealed partial SVC obstruction, under-filled left ventricle (LV), and a persistent mitral systolic anterior motion with increasing pressure gradient in the left ventricular outflow tract (LVOT). Surgical exposure uncovered an intrapericardial thrombus around the aortic graft compressing the SVC. Removal of the thrombus resulted in immediate haemodynamic improvement and elimination of both SVC and LVOT obstructions. A comprehensive TEE exam should always be performed, and all the structures should be visualized for the proper diagnosis and management of patients after cardiac surgery.

A Quadricupsid Aortic Valve

A Quadricupsid Aortic Valve Jagdish Butany, M.B.B.S., M.S., F.R.C.P.C.,∗¶ Michael J. Collins, B.Sc.,∗ Michael Duchnay, B.Sc.,∗ Dina El Demellawy, M.D., Ph.D.,∗ Jacek Karski, M.D.,† and Anthony C. Ralph-Edwards, M.D., F.R.C.S.C.‡¶ ∗Department of Pathology, †Department of Anesthesia, ‡Department of Cardiac Surgery, ¶Toronto Medical Laboratories, University Health Network and University of Toronto, Toronto, Ontario, Canada

Delirium and organic brain injury after cardiac surgery

Rita Katznelson, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Susan Abbey, Toronto General Hospital, University Health Network; W Scott Beattie, Toronto General Hospital, University Health Network; L Minkovich, Toronto General Hospital, University Health Network; Z Friedman, Mount Sinai Hospital, University Health Network; H Poonawala, Toronto General Hospital, University Health Network; J Karski, Toronto General Hospital, University Health Network; G Djaiani, Toronto General Hospital, University Health Network;

Impact of routine tranexamic acid in cardiac surgery: Single centre review

METHODS. In this report we present the major outcomes (mortality, stroke, renal failure, myocardial infarction, chest reopening for bleeding and infection) in 10,870 patients from a single centre who received TA before cardiac surgery. Following REB approval all patients who underwent heart surgery during 1999-2003 at our institution and received TA as a prophylactic measure to decrease blood loss were reviewed. Data from our prospectively collected database was analyzed for occurrence of major outcomes. Anesthetic management was uniform in all cases; all patients received TA before sternotomy (50-100 mg/kg.b.w.).