Justin Negri

IS INFORMED CONSENT IN CARDIAC SURGERY AND PERCUTANEOUS CORONARY INTERVENTION ACHIEVABLE

Background:  Medical and legal published work regularly discusses informed consent and patient autonomy before medical interventions. Recent discussions have suggested that Cardiothoracic surgeons’ risk adjusted mortality data should be published to facilitate the informed consent process. However, as to which aspects of medicine, procedures and the associated risks patients understand is unknown. It is also unclear how well the medical profession understands the concepts of informed consent and medical negligence. The aims of this study were to evaluate patients undergoing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) to assess their understanding of the risks of interventions and baseline level of understanding of medical concepts and to evaluate the medical staff’s understanding of medical negligence and informed consent.

Prolonged cardiac allograft ischemic time – no impact on long‐term survival but at what cost?

Abstract:  Introduction:  The aim of this paper was to review the outcomes of cardiac transplantation with regards to short‐ and long‐term survival, focusing particularly on patients who receive organs with long ischemic times and the resource utilization necessary to support such patients through their postoperative period.

Occlusive wrap dressing reduces infection rate in saphenous vein harvest site

BACKGROUND Infection in the saphenous vein harvest site is a common problem. We developed an occlusive circumferential wrap dressing technique that reduces skin edge tension, eliminates dead space, and prevents external contamination. We compared the surgical site infection rate using the wrap dressing technique with that of standard longitudinal dressings. METHODS. One hundred fifty-two consecutive patients were randomly assigned to receive either standard dressings or the wrap dressing. Data were collected in the hospital and then 4 to 6 weeks postoperatively. Superficial and deep wound infections were defined by the standard criteria from the Centers for Disease Control and Prevention. RESULTS The infection rate in the wrap group was 14% compared with 35%, for the standard group (p = 0.006). Multivariate analysis showed that wrap technique was the only significant predictor (negative) of infection (odds ratio, 0.19; p = 0.001). CONCLUSIONS In saphenous vein harvest wounds, the occlusive wrap dressing technique has the potential to reduce the rate of infection by 50%. This simple and inexpensive technique is also readily applicable to the radial artery harvest site in the arm and may provide similar benefit.

Long-term outcomes of cadaveric lobar lung transplantation: Helping to maximize resources

BACKGROUND Cadaveric lobar lung transplantation (CLLTx) represents a potential opportunity to address the bias against smaller recipients, especially children, on transplant waiting lists. The widespread use of CLLTx is hindered by the paucity of outcome data with respect to early complications and long-term lung function and survival. METHODS We looked at the long-term outcomes in 9 patients undergoing CLLTx since May 2003, including early surgical complications, pulmonary function tests, and survival. Patients were analyzed by whether the decision to perform CLLTx was elective (made at the time of listing) or emergent (surgical decision). RESULTS The incidence of early complications in the entire group was low, with the most common being atrial arrhythmias and prolonged thoracostomy tube. Lung function at 1 and 2 years (mean forced expiratory volume in 1 second % predicted +/- standard deviation of 73 +/- 18 and 60.5 +/- 27, respectively) was equivalent to living lobar transplant results. Overall survival was similar to 199 patients who received conventional cadaveric LTx during the same period. CONCLUSION This study suggests that CLLTx has a low complication rate with acceptable lung function and long-term survival, especially in cases where consideration has been given to CLLTx at the time of listing. CLLTx warrants consideration more often for patients of smaller physique to improve their chance of receiving LTx.

Recovery From Anthracycline Cardiomyopathy After Long-term Support With a Continuous Flow Left Ventricular Assist Device

We report the clinical course of a 16-year-old girl in remission from non-Hodgkins lymphoma who presented in cardiogenic shock due to a severe anthracycline cardiomyopathy. The patient was initially stabilized using central extracorporeal membrane oxygenation support, followed by conversion to a left ventricular assist device. Unexpected evidence of cardiac recovery 9 months after implant enabled device weaning during a 3-month period, culminating in successful device explantation 1 year after implant. The patient survives 18 months after explant in New York Heart Association class I, on conventional heart failure medical management and metabolic therapy.

Skeletonized internal thoracic artery harvesting reduces chest wall dysesthesia after coronary bypass surgery

OBJECTIVE A pain syndrome related to intercostal nerve injury during internal thoracic artery harvesting causes significant morbidity after coronary bypass surgery. We hypothesized that its incidence and severity might be reduced by using skeletonized internal thoracic artery harvesting rather than pedicled harvesting. METHODS In a prospective double-blind clinical trial, 41 patients undergoing coronary bypass were randomized to receive either unilateral pedicled or skeletonized internal thoracic artery harvesting. Patients were assessed 7 (early) and 21 (late) weeks postoperatively with reproducible sensory stimuli used to detect chest wall sensory deficits (dysesthesia) and with a pain questionnaire used to assess neuropathic pain. RESULTS At 7 weeks postoperatively, the area of harvest dysesthesia (percentage of the chest) in the skeletonized group (n = 21) was less (median, 0%; interquartile range, 0-0) than in the pedicled group (n = 20) (2.8% [0-13], P = .005). The incidence of harvest dysesthesia at 7 weeks was 14% in the skeletonized group versus 50% in the pedicled group (P = .02). These differences were not sustained at 21 weeks, as the median area of harvest dysesthesia in both groups was 0% (P = .89) and the incidence was 24% and 25% in the skeletonized and pedicled groups, respectively (P = 1.0). The incidence of neuropathic pain in the skeletonized group compared with the pedicled group was 5% versus 10% (P = .6) at 7 weeks and 0% versus 0% (P = 1.0) at 21 weeks. CONCLUSIONS Compared with pedicled harvesting, skeletonized harvesting of the internal thoracic artery provides a short-term reduction in the extent and incidence of chest wall dysesthesia after coronary bypass, consistent with reduced intercostal nerve injury and therefore the reduced potential for neuropathic chest pain.

Carbon dioxide insufflation in open-chamber cardiac surgery: A double-blind, randomized clinical trial of neurocognitive effects

OBJECTIVE The aims of this study were first to analyze neurocognitive outcomes of patients after open-chamber cardiac surgery to determine whether carbon dioxide pericardial insufflation reduces incidence of neurocognitive decline (primary end point) as measured 6 weeks postoperatively and second to assess the utility of carbon dioxide insufflation in cardiac chamber deairing as assessed by transesophageal echocardiography. METHODS A multicenter, prospective, double-blind, randomized, controlled trial compared neurocognitive outcomes in patients undergoing open-chamber (left-sided) cardiac surgery who were assigned carbon dioxide insufflation or placebo (control group) in addition to standardized mechanical deairing maneuvers. RESULTS One hundred twenty-five patients underwent surgery and were randomly allocated. Neurocognitive testing showed no clinically significant differences in z scores between preoperative and postoperative testing. Linear regression was used to identify factors associated with neurocognitive decline. Factors most strongly associated with neurocognitive decline were hypercholesterolemia, aortic atheroma grade, and coronary artery disease. There was significantly more intracardiac gas noted on intraoperative transesophageal echocardiography in all cardiac chambers (left atrium, left ventricle, and aorta) at all measured times (after crossclamp removal, during weaning from cardiopulmonary bypass, and at declaration of adequate deairing by the anesthetist) in the control group than in the carbon dioxide group (P < .04). Deairing time was also significantly longer in the control group (12 minutes [interquartile range, 9-18] versus 9 minutes [interquartile range, 7-14 minutes]; P = .002). CONCLUSIONS Carbon dioxide pericardial insufflation in open-chamber cardiac surgery does not affect postoperative neurocognitive decline. The most important factor is atheromatous vascular disease.

Fast-track cardiac surgery: application in an Australian setting.

In response to the current state of healthcare in Australia, our unit has employed a fast-track policy for low-risk cardiac surgery patients since January 2000. This study was designed to examine the safety and efficacy of this policy. From July 2001 to June 2004, 342 (23%) of 1,488 patients undergoing cardiac surgery were identified preoperatively as suitable for fast-track recovery. There was a significantly shorter median time to extubation (4 hr vs 9 hr), reduced intensive care unit stay (8 hr vs 26 hr), and a lower rate of readmission to the intensive care unit (0.6% vs 4.2%) for those fast tracked compared to the other patients. The fast-track group had a lower incidence of complications and significantly decreased median length of hospital stay (5 vs 7 days). We concluded that this policy accurately identifies the low-risk cardiac surgery patients suitable for less intensive postoperative recovery.

Australian Experience with VAD as a Bridge to Paediatric Cardiac Transplantation

The Royal Childrens Hospital, Melbourne is the National Paediatric Heart Transplant Centre of Australia. A variety of ventricular assist devices (VADs) have been used effectively as a bridge to heart transplantation in adult patients, however, the experience in the paediatric population is limited. We present our initial experience using the Thoratec and Medos VAD systems as a bridge to heart transplantation in the designated centre for paediatric cardiac transplantation in Australia. The medical records of all patients supported with a Thoratec or Medos VAD at the RCH from July 2005 to July 2007 were retrospectively reviewed. Seven patients between 5 and 16 years of age were supported with the Thoratec or Medos VAD during the period of study. All of the patients were supported with a left sided ventricular assist device (LVAD). The length of time supported ranged from 6 to 230 days, with a median of 22 days. Co-morbidities included surgical re-exploration for bleeding, cannula site wound infections and thromboembolic events. Two patients died before a donor heart became available. From our limited experience, the use of a VAD as a bridge to heart transplantation is a feasible option for children with end stage cardiac failure.

Mycotic Pseudoaneurysms of the Coronary Arteries.

Mycotic coronary artery aneurysms are rare and are often fatal without early recognition and prompt surgical management.