Jan Rogowski

Atrial fibrillation after coronary artery bypass grafting without cardiopulmonary bypass

OBJECTIVE Atrial fibrillation is the most common complication after heart surgery. It rarely has a fatal outcome but causes patient instability, prolongs hospital stay, or even is the reason for perioperative infarction. Although conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass has excellent short-term and long-term results, the number of coronary operations on a beating heart without cardiopulmonary bypass is still growing. To reduce surgical trauma, off-pump coronary artery bypass grafting via sternotomy (OPCABG) or minimally invasive direct vision coronary artery bypass grafting (MIDCABG) via small thoracotomy are performed. The aim of this study was to estimate the frequency of atrial fibrillation in patients after myocardial revascularization without cardiopulmonary bypass. METHODS A retrospective analysis of 48 patients undergoing myocardial revascularization without cardiopulmonary bypass was performed. Twenty-four patients underwent OPCABG and 24 were operated using the MIDCABG technique. The incidence of cardiac arrhythmias was analyzed since operation to the fourth postoperative day. Each patient had continuous ECG monitoring with option of arrhythmia analysis during ICU stay. After discharge from ICU 24-h ECG monitor studies were carried out. Surface 12-lead ECG was accomplished once a day, and additionally each time symptoms of cardiac arrhythmia occurred. Risk factors of atrial fibrillation were estimated. RESULTS Atrial fibrillation occurred in 25% of patients after MIDCABG, in 29% after OPCABG, and in 18% after CABG with cardiopulmonary bypass. This difference has no statistical significance. Risk factors and incidence of postoperative complications were comparable in all groups. CONCLUSIONS Atrial fibrillation is a common complication after procedures of myocardial revascularization, performed with or without cardiopulmonary bypass. The occurrence is not dependent on the type of operation.

Atrial fibrillation after coronary artery bypass grafting: does the type of procedure influence the early postoperative incidence?

OBJECTIVE Atrial fibrillation (AF), the common postoperative complication, has been observed after coronary artery bypass grafting (CABG) in 7--40% of patients. Cardiopulmonary bypass (CPB), eliminated in off-pump operations (OPCABG) may decrease the incidence of AF, whereas the combination of CABG with heart valve replacement may result in more frequent postoperative atrial fibrillation. The aim of our study was to compare the early postoperative AF incidence rate during ICU stay in three groups of patients: after CABG, OPCABG, and CABG combined with valve replacement. MATERIAL AND METHODS A prospective study of 906 consecutive patients was carried out between January 1999 and January 2000. Clinical profile of 906 patients, including factors having potential influence on postoperative AF did not showed any significant differences between the groups. The presence of arrhythmia history was the reason of excluding 85 patients from the statistical analysis. The observation was performed in each case during ICU-stay, using a HP system for continuous automated arrhythmia analysis. Early postoperative incidence of AF was recorded and compared between three groups of patients: 650 after conventional CABG, 118 after OPCABG, and 53 after CABG combined with valve replacement. Chi-square and a Mann--Whitney tests, Statistica 5.0 PL were used for the statistical analysis. RESULTS Atrial fibrillation occurred during the postoperative ICU stay in 9.8% of patients after CABG, in 10.2% after OPCABG, and in 21% after CABG combined with valve replacement. There was no significant difference between CABG and OPCABG groups (P=0.965). The confidence interval of the odds ratio ranges from 0.5 to 1.85. Consequently, an increased risk would be possible for both methods. We observed a statistically significant increase of the early postoperative atrial fibrillation incidence rate in patients after CABG combined with valve replacement, when compared with both CABG + OPCABG groups (P=0.005). CONCLUSIONS (1) Atrial fibrillation is a common postoperative complication after myocardial revascularization procedures which prolongs ICU stay. (2) The study did not show that the incidence of postoperative AF is influenced by the technique of coronary artery bypass grafting: with or without CPB. (3) The prevalence of postoperative AF increase when CABG is combined with valve replacement.

Influence of baseline left ventricular function on the clinical outcome of surgical ventricular reconstruction in patients with ischaemic cardiomyopathy.

AIMS The Surgical Treatment for Ischemic Heart Failure (STICH) trial demonstrated no overall benefit when surgical ventricular reconstruction (SVR) was added to coronary artery bypass grafting (CABG) in patients with ischaemic cardiomyopathy. The present analysis was to determine whether, based on baseline left ventricular (LV) function parameters, any subgroups could be identified that benefited from SVR. METHODS AND RESULTS Among the 1000 patients enrolled, Core Lab measures of baseline LV function with adequate quality were obtained in 710 patients using echocardiography, in 352 using cardiovascular magnetic resonance, and in 344 using radionuclide imaging. The relationship between LV end-systolic volume index (ESVI), end-diastolic volume index, ejection fraction (EF), regional wall motion abnormalities, and outcome were first assessed only by echocardiographic measures, and then by 13 algorithms using a different hierarchy of imaging modalities and their quality. The median ESVI and EF were 78.0 (range: 22.8-283.8) mL/m2 and 28.0%, respectively. Hazard ratios comparing the randomized arms by subgroups of LVESVI and LVEF measured by echocardiography found that patients with smaller ventricles (LVESVI <60 mL/m2) and better LVEF (≥33%) may have benefitted by SVR, while those with larger ventricles (LVESVI >90 mL/m(2)) and lower LVEF (≤25%) did worse with SVR. Algorithms using all three imaging modalities found a weaker relationship between LV global function and the effects of SVR. The extent of regional wall motion abnormality did not influence the effects of SVR. CONCLUSIONS Subgroup analyses of the STICH trial suggest that patients with less dilated LV and better LVEF may benefit from SVR, while those with larger LV and poorer LVEF may do worse. Clinical Trial Registration #: NCT00023595.

Incidence- and mortality-related risk factors of acute kidney injury requiring hemofiltration treatment in patients undergoing cardiac surgery: a single-center 6-year experience.

OBJECTIVE To evaluate the incidence and mortality risk factors of severe acute kidney injury (AKI) requiring hemofiltration treatment after cardiac surgery. DESIGN A single-center, retrospective, case-control study. SETTING A post-cardiac-surgical intensive care unit at a university hospital. PARTICIPANTS Nine thousand two hundred twenty-two consecutive adult cardiac surgical patients, among whom 107 developed severe AKI. INTERVENTIONS Continuous venovenous hemofiltration. MEASUREMENTS AND MAIN RESULTS The overall incidence of severe AKI was 1.2%, but it differed with the type of surgical procedure including coronary artery bypass graft surgery, 0.4%; heart valves, 1.7%; aorta surgery, 5.4%; ventricle septum rupture, 52.6%; and other, 6.5%. From 6 predictors of 30-day mortality identified by univariate logistic regression (age, preoperative serum creatinine, New York Heart Association class, resternotomy, postoperative myocardial infarction, and postoperative use of intra-aortic balloon pump [IABP]), only the need for the postoperative use of IABP (odds ratio, 2.9; p = 0.01) and resternotomy (odds ratio, 3.4; p = 0.005) proved stable in multivariate analysis. Kaplan-Meier analysis identified the following overall mortality risk factors: age (p = 0.03), New York Heart Association class ≥II (p = 0.0004), resternotomy (p = 0.02), postoperative myocardial infarction (p = 0.01), and IABP (p = 0.03). CONCLUSIONS The risk of developing severe AKI depended on the type of cardiac surgical procedure. Thirty-day mortality was associated with severe perioperative circulation impairment or bleeding, but overall long-term mortality was additionally predicted by age, postoperative myocardial infarct, and preoperative circulation status.

Off-pump coronary surgery may reduce stroke, respiratory failure, and mortality in octogenarians.

BACKGROUND Octogenarians are a challenging group of patients referred for cardiac surgery. The aim of this study is to assess early outcomes of coronary artery bypass grafting (CABG) performed in the elderly population. METHODS We performed a meta-analysis of all published observational studies comparing early results of conventional CABG surgery and off-pump CABG surgery in patients aged 80 years or older. The outcomes of interest were mortality, stroke, respiratory failure, renal failure, incidence of support with intraaortic balloon pump, and incidence of postoperative atrial fibrillation. The random effects model was used. RESULTS Fourteen studies were analyzed. The total number of included subjects was 4,991, of whom 3,113 underwent conventional CABG surgery (62.4%), and 1,878 (37.6%) underwent off-pump CABG surgery. The rates of mortality, stroke, and respiratory failure were significantly higher in the conventional CABG surgery group. CONCLUSIONS These results confirm that off-pump CABG surgery remains a valuable option of surgical myocardial revascularization, and may optimize the outcome in senior patients.

Implication of Right Ventricular Dysfunction on Long-term Outcome in Patients with Ischemic Cardiomyopathy Undergoing Coronary Artery Bypass Grafting with or without Surgical Ventricular Reconstruction

OBJECTIVE Whether right ventricular dysfunction affects clinical outcome after coronary artery bypass grafting with or without surgical ventricular reconstruction is still unknown. The aim of the study was to assess the impact of right ventricular dysfunction on clinical outcome in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting with or without surgical ventricular reconstruction. METHODS Of 1000 patients in the Surgical Treatment for Ischemic Heart Failure with coronary artery disease, left ventricular ejection fraction 35% or less, and anterior dysfunction, who were randomized to undergo coronary artery bypass grafting or coronary artery bypass grafting + surgical ventricular reconstruction, baseline right ventricular function could be assessed by echocardiography in 866 patients. Patients were followed for a median of 48 months. All-cause mortality or cardiovascular hospitalization was the primary end point, and all-cause mortality alone was a secondary end point. RESULTS Right ventricular dysfunction was mild in 102 patients (12%) and moderate or severe in 78 patients (9%). Moderate to severe right ventricular dysfunction was associated with a larger left ventricle, lower ejection fraction, more severe mitral regurgitation, higher filling pressure, and higher pulmonary artery systolic pressure (all P < .0001) compared with normal or mildly reduced right ventricular function. A significant interaction between right ventricular dysfunction and treatment allocation was observed. Patients with moderate or severe right ventricular dysfunction who received coronary artery bypass grafting + surgical ventricular reconstruction had significantly worse outcomes compared with patients who received coronary artery bypass grafting alone on both the primary (hazard ratio, 1.86; confidence interval, 1.06-3.26; P = .028) and the secondary (hazard ratio, 3.37; confidence interval, 1.36-8.37; P = .005) end points. After adjusting for all other prognostic clinical factors, the interaction remained significant with respect to all-cause mortality (P = .022). CONCLUSIONS Adding surgical ventricular reconstruction to coronary artery bypass grafting may worsen long-term survival in patients with ischemic cardiomyopathy with moderate to severe right ventricular dysfunction, which reflects advanced left ventricular remodeling.

Infrared thermography: applications in heart surgery

Infrared thermography has become a way to monitor thermal abnormalities present in number of diseases and physical injuries. It is used as an aid to diagnosis, prognosis and therapy. Results obtained using the last generation of equipment (computer assisted thermographic systems, detectors without liquid nitrogen cooling system) and new techniques as dynamic thermography with independent source of driving radiation shows that it is a reliable tool for medical assessment and diagnosis. Most important--the Infrared Thermography is a non-invasive measurement technique, with non-stress for patients. This paper describes Intraoperative Thermoangiography during coronary bypass surgery.

Paraesophageal Hernia Repair Followed by Cardiac Tamponade Caused by ProTacks

We describe a case of cardiac tamponade caused by ProTacks Autosuture used for mesh fixation during a laparoscopic Nissen operation with giant paraesophageal hernia repair. Perforations of the posterior descendent artery and epicardial vein of the right ventricle were caused by ProTacks used for Parietex Composite Mesh fixation. Protruding ProTacks were secured from inside the pericardiac sac with a synthetic vascular patch during emergency sternotomy. Quick and multidisciplinary cooperation ended with emergency cardiothoracic procedure saving the patients life and preventing further damage to the heart muscle and its vessels.

Microscopic examination of bone marrow aspirate in healthy adults - comparison of two techniques of slide preparation.

Introduction:  According to the International Council for Standardization in Hematology (ICSH) guidelines for the standardization of bone marrow specimens and reports, smears from bone marrow aspirates for microscopic examination should be prepared using two techniques simultaneously: the wedge‐spread and the crush technique. However, the outcomes of these techniques have never been compared.

Comparison of haemodynamics and myocardial injury markers under desflurane vs. propofol anaesthesia for off-pump coronary surgery. A prospective randomised trial.

BACKGROUND Several studies have highlighted that volatile anaesthetics improve myocardial protection in cardiopulmonary bypass coronary surgery. However, the haemodynamic effect of desflurane in off-pump coronary surgery has not been clarified yet. Our study hypothesis was that desflurane-fentanyl anaesthesia could decrease myocardial injury markers and improve haemodynamics compared to propofol-fentanyl in patients undergoing off-pump coronary surgery. METHODS DESIGN Prospective, randomised open-lable study. Sixty elective patients with left ventricular ejection fraction above 30% received either desflurane (group D, n = 32) or propofol (group P, n = 28), in addition to fentanyl and vecuronium bromide anaesthesia for off-pump coronary surgery. Assessment of haemodynamic function included thermodilution continuous cardiac output and right ventricular end diastolic volume. RESULTS No significant differences in cardiac output, stroke volume and mean arterial pressure were noted between groups. The only observed difference in haemodynamic profile was that group D demonstrated improved stability, expressed as left ventricular stroke work index (LVSWI). Decrease in LVSWI after performing distal anastomoses was smaller in D compared to P (median value: -14.3 and -19.8 [g m m⁻² beat⁻¹]), respectively (P = 0.029). Oxygen uptake index (VO₂I) and oxygen extraction ratio (OER) after skin incision were lower in D, while blood lactate concentration was slightly higher after surgery in D compared to P. The groups did not differ with respect to CK-MB and troponin I concentration. CONCLUSIONS This study demonstrated no difference between desflurane and propofol anaesthesia for off-pump coronary surgery in major haemodynamic parameters, as well as in myocardial injury markers and the long-term outcome. However, the study indicated that desflurane might accelerate recovery of myocardial contractility, as assessed by LVSWI. Lower oxygen uptake and elevated lactate under desflurane anaesthesia indicated a discrete shift towards anaerobic metabolism. CLINICAL TRIAL REGISTRATION INFORMATION NCT00528515 (http://www.clinicaltrials.gov/ ct2/show/NCT00528515?term = NCT00528515&rank = 1).