Michael Rowland

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.

The effects of ageing on the response to cardiac surgery: protective strategies for the ageing myocardium.

Abstractyounger muscle. 4)Oral CoQ10 therapy before cardiac surgery improves efficiency of mitochondrial energy production, improves post-operative heart function, reduces intra-operative myocardial damage and shortens hospital stay.

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.

Tranexamic Acid in cardiac surgery and postoperative seizures: a case report series.

With the recent withdrawal of the antifibrinolytic aprotinin from the market, tranexamic acid (TxA) has become more widely used. This change has led to increasing concern about the side-effect profile of TxA, particularly the incidence of postoperative seizures. In this case series, we describe 7 patients over an 18-month period who had open-chamber cardiac surgery and developed seizures in the postoperative period. This incidence is increased compared with that of a cohort of patients in the previous 36 months who did not receive TxA (0.66% versus 0%; P < .05). The exact mechanism of TxA-induced seizures is thought to be via inhibition of gamma-aminobutyric acid receptors in neurons. Data from the neurosurgical literature show a well-established link between this antifibrinolytic and seizures. There is now increasing awareness of this association in cardiac surgery, particularly when high TxA doses are used.

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.

Nontraumatic localized dehiscence of the proximal ascending aorta through an aortic valve commissure

Acute dissection of the ascending aorta is a life-threatening condition that requires timely recognition and management. Here we describe an unusual variant of acute dissection involving a localized tear in the proximal ascending aorta through the commissure of the left and noncoronary cusps of the aortic valve causing aortic regurgitation.

Aortic valve replacement for aortic stenosis during orthotopic cardiac transplant.

Although concomitant coronary bypass, and mitral and tricuspid valve surgery have been used to expand the donor pool for cardiac transplantation, aortic valve disease is considered an absolute contraindication for use of an offered organ. A case is presented with the successful use of an organ requiring concomitant aortic valve replacement for calcific aortic stenosis on a congenitally bicuspid valve. Eighteen-month follow-up documented excellent allograft function with a normally functioning mechanical aortic prosthesis. Aortic valve disease in offered organs can be successfully treated with aortic valve replacement at the time of transplantation and should not preclude the use of the organ in the setting of a recipient who is a candidate for a marginal allograft.

Cardiac surgery in Australia: The National Heart Foundation of Australia registry

Abstract The National Heart Foundation (NHF) of Australia publishes an annual report on all cardiac surgery performed in Australia. Only 2 other countries have national cardiac surgery databases. In the U.S.A., the Society of Thoracic Surgeons (STS) has established a large voluntary database which does not, however, include complete national statistics. The STS uses Bayesian analysis to predict operative risk. A similar system in the U.K. has been useful for predicting surgical morbidity and mortality. The most recent NHF report, published in August 1993, covers surgical procedures performed in 1991. In that year, 16,688 procedures were performed, a 10.3% increase over the previous year. Operative mortality was 2.6%. Most procedures were coronary artery bypass grafts (69.4% or 11,586 procedures). Although the NHF registry is a valuable resource, it may be necessary to expand this national database so that national results can be analysed in greater detail.