Kuan-Ming Chiu

Carbon dioxide embolism during endoscopic saphenous vein harvesting in coronary artery bypass surgery

OBJECTIVES Our objectives were to determine the incidence and severity and the time course of the CO(2) embolism during endoscopic saphenous vein harvesting with CO(2) insufflation in coronary artery bypass surgery with transesophageal echocardiography monitoring. METHODS Four hundred three consecutive patients scheduled for off-pump coronary artery bypass grafting surgery or femoral-to-popliteal artery bypass grafting surgery were prospectively studied. Multiplane transesophageal echocardiography with a new transgastric view was used to monitor CO(2) bubbles in the inferior vena cava and hepatic vein. RESULTS CO(2) embolisms occurred in 17.1% of patients. Minimal, moderate, and massive CO(2) embolisms occurred in 13.1%, 3.5%, and 0.5%, respectively. The occurrence of moderate and massive CO(2) embolisms was frequently associated with the surgical manipulation of branches of saphenous veins. No significant risk factors were identified in multiple logistic regression analysis. CONCLUSION The incidence of significant CO(2) embolism during endoscopic saphenous vein harvesting with CO(2) insufflation procedures was more than 4%. Continuous transesophageal echocardiographic monitoring of the CO(2) bubbles in the inferior vena cava is essential in early detection and can help to prevent the development of significant CO(2) embolisms in these patients.

Carvedilol can restore the multifractal properties of heart beat dynamics in patients with advanced congestive heart failure

INTRODUCTION Human heart beats in an extremely inhomogeneous and non-stationary manner. Recent study has demonstrated that it belongs to a class of signals called multifractal. Loss of multifractality was also uncovered in patients with congestive heart failure. We investigated whether carvedilol could restore the multifractal properties in a group of patients with advanced congestive heart failure. METHODS AND RESULTS A Holter ECG recording was obtained before and 1 and 3 months after titrated addition of carvedilol therapy in 10 patients with advanced congestive heart failure. Multifractal spectrum, detrended fluctuation analysis (DFA) as well as the traditional time- and frequency-domain heart rate variability (HRV) parameters were compared before and after carvedilol therapy together with those in age and sex-matched normal control. The results showed that the multifractal spectrum tau(q) vs. q of N-N interval time series returned toward normal during carvedilol treatment. All the traditional HRV parameters and the short-term DFA improved significantly after 3 months of carvedilol therapy. CONCLUSION We concluded that the deteriorated multifractal properties could be reversed by carvedilol treatment in patients with advanced congestive heart failure.

Local infusion of bupivacaine combined with intravenous patient-controlled analgesia provides better pain relief than intravenous patient-controlled analgesia alone in patients undergoing minimally invasive cardiac surgery

OBJECTIVE This prospective randomized double-blind study examined the effect of local wound infusion of anesthetics on pain control in the thoracotomy wound of patients undergoing minimally invasive cardiac surgery. METHODS Patients who underwent coronary artery bypass grafting or cardiac valvular procedures via a minimally invasive thoracotomy were studied. Patients were enrolled and randomly allocated to two groups with different modalities of postoperative analgesia. The thoracotomy wound infusion group received 0.15% bupivacaine infused continuously at 2 mL/h through a catheter embedded in the wound, as well as intravenous patient-controlled analgesia. The control group had patient-controlled analgesia alone with a sham thoracotomy wound infusion of normal saline. Verbal analog pain scores (0-10 points) and recovery profiles were investigated. RESULTS There were 19 patients in each group for complete data analysis. On the first day after the operation, infusion of local anesthetics significantly reduced the verbal analog pain scores both at rest and during motion (thoracotomy wound infusion vs control). The improved pain relief with thoracotomy wound infusion persisted at day 3 and even at 3 months after the operation. No difference was noted about time to extubation, length of intensive care unit stay, or hospital stay. CONCLUSION In this controlled double-blind study, thoracotomy wound infusion and patient-controlled analgesia were superior to patient-controlled analgesia alone in reducing pain at 1, 3, and 90 days after minimally invasive cardiac surgery.

Spiral Saphenous Vein Graft for Portal Vein Reconstruction in Pancreatic Cancer Surgery

The curative strategy for most pancreatic cancer is surgical resection. Extensive resection with lymph node dissection is the key to providing long-term survival. However, early diagnosis of pancreatic cancer is not always possible (ie, resectability is limited). One reason for such a nonresectable condition is vascular invasion or encasement. Portal vein involvement has been a contraindication for pancreatic cancer surgery for most general surgeons. Combining oncologic and vascular surgeons in the procedure has been a good solution. A multidisciplinary approach that includes general and vascular surgeons is appropriate in selected patients requiring vascular reconstruction at the time of pancreatectomy. The objective of this paper is to report a case in which spiral saphenous vein was used for portal vein reconstruction during pancreatic cancer resection.

Tetrandrine ameliorated reperfusion injury of small bowel transplantation

PURPOSE In small bowel transplantation, the bowel graft is susceptible to reperfusion injury. This study investigated the effects of tetrandrine, a bisbenzylisoquinoline alkaloid, on the development of intestinal reperfusion injury in small bowel transplantation in pigs. MATERIALS AND METHODS Pigs underwent small bowel transplantation and were treated with tetrandrine or a vehicle. Blood and small bowel specimens were harvested at 1, 3, and 24 hours after reperfusion. Histopathologic analysis of the small bowel was assessed for tissue damage. Serum levels of tumor necrosis factor-alpha, interleukin-1beta (IL-1beta), and IL-6 were measured by enzyme-linked immunosorbent assay. Reverse-transcriptase polymerase chain reaction analysis was performed to analyze the expression of proinflammatory cytokines, and immunohistochemical analysis was used to study the expression of intercellular adhesion molecule-1 (ICAM-1) in the small bowel. Myeloperoxidase staining detected neutrophil infiltration in the small bowel and the number of myeloperoxidase positively stained cells was counted. RESULTS Pigs receiving small bowel transplantation had elevated serum proinflammatory cytokine levels. The transplanted small bowel showed mucosal damage, increased expression of proinflammatory cytokines and ICAM-1, and prominent neutrophil infiltration. Tetrandrine administration reduced mucosal damage, serum and tissue proinflammatory cytokine levels, ICAM-1 expression, and neutrophil accumulation in the transplanted small bowel. CONCLUSIONS Tetrandrine reduced the reperfusion injury in porcine intestinal transplantation during the first 24 hours after the procedure.

Left Ventricle Apical Conduit to Bilateral Subclavian Artery in a Patient With Porcelain Aorta and Aortic Stenosis

Severe atherosclerosis or calcification of the ascending aorta is associated with increased morbidity and mortality rates in patients who underwent cardiac operations. Several techniques had been used to avoid the manipulation of the ascending aorta during cardiac surgery. We reported our extra-anatomic approach in a patient with coronary artery disease and severe aortic stenosis with porcelain aorta. A 76-year-old man with chronic obstructive pulmonary disease, aortic stenosis, and coronary artery disease was scheduled to have cardiac surgery. After a standard median sternotomy, we found that the ascending aorta was severely calcified. The surgical strategy was changed to the construction of the composite conduit from the left ventricle (LV) apex to bilateral subclavian artery and coronary artery bypass grafting with saphenous vein. The right axillary artery and right atrium were cannulated to set up the cardiopulmonary bypass. A composite graft with a 21-mm bioprosthetic valve (Hancock II, Medtronic Inc, Minneapolis, Minn) interposed into a 22–11–11 mm Y-shaped Hemashield graft (Meadox, Hemashield, Boston Scientific, Boston, Mass) was constructed. The proximal part of the composite graft was anastomosed directly to the LV apex. The distal portions of this composite graft were anastomosed end-to-side to the bilateral subclavian artery. Intraoperative transesophageal echocardiography demonstrated a wide opened connection and unlimited blood flow from the LV apex to the conduit (Figure 1). Flow in the bilateral proximal subclavian artery showed reversed flow, which highlighted the adequacy of new LV outflow tract. The postoperative plain chest film showed the unusual location of prosthetic valve (Figure 2). Magnetic resonance angiography showed the patency of this apical composite conduit (Figure 3). The patient had an uneventful recovery. In current practice, ascending aortic calcification or atherosclerosis could be identified by epiaortic ultrasound; however, preoperative noninvasive study such as high-resolution, noncontrast computed tomography could be used for this purpose.

Endoscopic harvest of saphenous vein: a lesson learned from 1,348 cases

BackgroundEndoscopic harvest of saphenous vein is a relatively new technique developed to minimize the wound and postoperative complications. This technique has gained patients’ acceptance and become popular in cardiac surgical practices. Because most centers have limited experience with this approach, the authors summarize the clinical profiles of patients undergoing endoscopic vessel harvest (EVH).MethodsBetween March 2001 and August 2006, 1,348 patients (945 men and 403 women) with a mean age of 67.2 years (range, 28–89 years) underwent EVH of saphenous vein for coronary artery bypass surgery, peripheral artery reconstruction, and miscellaneous conditions. The EVH technique was performed using the Vasoview system (Guidant, Menlo Park, CA, USA) under the assistance of carbon dioxide (CO2) insufflation.ResultsTechnical success was achieved in 98.6% of the cases. Two saphenous veins were discarded because of obvious vein injury. The mean harvest time was 45 min: 68 min for the first 50 cases and 23 min for the last 200 cases. Nearly all the patients (98%) had saphenous vein harvested only from the thighs, whereas only 1.5% of the patients had saphenous vein harvested from the legs. Postoperative wound complications were experienced by 61 patients including 25 tract hematomas, 19 wound dehiscences or poor healing, 16 wound infections, and 1 overlying skin necrosis. Overall, 13 subsequent revisions were required for these complications. Detectable air embolisms occurred for 143 patients and numbness in the saphenous nerve territory for 169 patients.ConclusionThe findings showed EVH of saphenous vein to be a valid alternative to open saphenectomy, providing excellent surgical results. Therefore, EVH should be considered as the standard of care for saphenous vein harvest.

Innominate Artery Cannulation for Aortic Surgery

When disease involving the ascending aorta or aortic arch precludes ascending aortic cannulation, axillary artery cannulation is used for cardiopulmonary bypass. An additional incision and the relatively small caliber of the axillary artery are the drawbacks of this approach. Innominate artery cannulation using the same sternotomy wound is a simple and effective alternative.

Antimicrobial effect of continuous lidocaine infusion in a Staphylococcus aureus-induced wound infection in a mouse model.

AbstractContinuous infusion of local anesthetics in surgical wounds has been shown to be an effective technique for postoperative analgesia. To investigate the potential antimicrobial effect of continuous local anesthetic infusion, we adapted a mouse model of surgical wound infection to examine effects on antibacterial response. Forty male BALB/c mice were randomized into 2 groups. An incision wound was made over the dorsal flank and instilled with Staphylococcus aureus. An osmotic pump was then implanted to deliver either 0.9% NaCl or 2% lidocaine continuously. Each wound was cultured postoperatively at 2 days, and the colony count of S. aureus was determined. Results showed that the number of colony-forming units of S. aureus measured in wounds treated with lidocaine displayed a nearly 10-fold reduction compared to the wounds in the saline group (P = 0.009). The demonstrated antibacterial activity indicates that local anesthetic infusion may play a role in prophylaxis for surgical wound infections.

Less Invasive Mitral Valve Surgery via Right Minithoracotomy

BACKGROUND/PURPOSE Current trends in cardiac surgical intervention are moving toward less invasiveness, with smaller wound or sternum-sparing, less pump time or off-pump, and beating rather than arrested heart. Data on the efficacy and safety of these newer less invasive techniques, as well as their cosmetic results, are limited. This study analyzed the results of a sternum-sparing mitral valve operation. METHODS Thirty patients with mitral valve diseases, including 20 who underwent mitral valve repair and 10 mitral valve replacement, were enrolled. Cardiopulmonary bypass was established via femoral cannulation, and blood cardioplegic arrest was induced by using a percutaneous, transthoracic cross-clamp. The main surgical wound was made over the lateral border of the right breast. Two additional small wounds were required for the transthoracic aortic clamp and the mitral retractor. RESULTS There was no operative mortality, and all patients had an uneventful recovery. Two patients underwent redo mitral surgery. Nine associated procedures were performed including tricuspid valve annuloplasty in six patients, tricuspid valve replacement in two patients and atrial septal defect repair in one patient. The length of the main wound was between 5.8 and 7.8 cm (mean, 7.1 cm). The mean cardiopulmonary bypass time and cross-clamp time were 91.1 and 43.7 minutes, respectively. Although the length of stay was not significantly reduced compared with traditional median sternotomy, all patients had satisfactory results with good cosmesis. CONCLUSION Sternum-sparing mitral valve surgery appears to be a safe and effective alternative to conventional mitral valve surgery; it is less invasive and provides superior cosmetic results for patients.