Mohamed Bentala

Tolerance of intraoperative hemoglobin decrease during cardiac surgery

It has been suggested that a decrease of at least 50% from the preoperative hemoglobin (Hb) level during cardiac surgery is associated with adverse outcomes even if the absolute Hb level remains above the commonly used transfusion threshold of 7.0 g/dL. In this study the relation between intraoperative Hb decline of at least 50% and a composite endpoint was analyzed.

Totally thoracoscopic left atrial Maze: standardized, effective and safe

OBJECTIVES The totally thoracoscopic left atrial Maze (TT-Maze) is a relatively new surgical solution for the treatment of atrial fibrillation (AF). The procedure consists of a complete left atrial Maze, which is performed by video-assisted thoracoscopy with the use of radiofrequency ablation. We describe our rhythm results as well as our learning curve experience of the TT-Maze. METHODS To evaluate the learning curve, all consecutive patients who underwent a TT-Maze and were operated by one surgeon (Bart P. Van Putte) were included in the study. The endpoint of surgery was sinus rhythm with a bidirectional block of the box and pulmonary veins. RESULTS A total of 83 patients were included. Fifty percent of the patients had paroxysmal AF. The mean indexed left atrial volume was 44 ± 15 ml/m(2) and 38% of the patients had a previous catheter ablation for AF. During a mean follow-up of 10.9 ± 4.9 months, there were no major events. At latest follow-up, 82% of the patients did not have a single registration of AF or other atrial tachyarrhythmias longer than 30 s. Patients without AF were also free from anti-arrhythmic drugs in 90% of the cases, free from coumadins or direct oral anticoagulants in 63% of the cases and free from both in 58% of the cases. CONCLUSIONS After almost 1-year follow-up, the TT-Maze is proved to be a successful, safe and reproducible strategy for the treatment of all types of AF including patients with enlarged left atria and previously failed catheter ablation.

Association of perioperative troponin and atrial fibrillation after coronary artery bypass grafting

OBJECTIVES Prediction of atrial fibrillation (AF) after coronary artery bypass grafting (CABG) may lead to preventive or early treatment and improved outcome. We investigated the association of serial perioperative cardiac troponin T (cTNT) measurements with postoperative AF in patients undergoing CABG. METHODS In a retrospective analysis of prospectively collected data, 3148 patients undergoing elective CABG were evaluated. cTNT values were routinely determined before the start of surgery (cTNT0), at arrival on the intensive care unit (cTNT1) and 8-12 h later (cTNT2). Measurement of cTNT was continued until the peak value was reached. The development of AF during hospital stay was scored. The association between cTNT (cTNT0, cTNT1, cTNT2 and cTNTmax in first 48 h) and AF was calculated in univariable and multivariable analysis. RESULTS AF occurred in 1080 (34%) patients. cTNT0, cTNT2 and cTNTmax were significantly and positively associated with postoperative AF (P < 0.001) in a univariable analysis, whereas a trend was seen for cTNT1 (P = 0.051). Advanced age, inotropic support and postoperative infection were independently associated with postoperative AF after logistic regression analysis, but cTNT was not. Categorizing patients by inotropic support into categories of inotropic support duration (none, <48 h, >48 h), the mean cTNT values were significantly higher among patients with AF in each category (all P < 0.001). Perioperative cTNT was significantly higher in patients with postoperative complications, longer hospital stay and reduced in-hospital survival. CONCLUSIONS Perioperative cTNT is univariably associated with postoperative AF after CABG, but not independently. Further, no clinically useful cut-off point for preventive or early treatment could be identified. Both perioperative cTNT and postoperative AF are associated with negative outcome and prolonged hospital stay.

Defining indications for selective chest radiography in the first 24 hours after cardiac surgery.

OBJECTIVE In the intensive-care unit (ICU), chest radiographs (CXRs) are frequently obtained routinely for postoperative cardiac surgery patients, despite the fact that the efficacy of routine CXRs is known to be low. We investigated the efficacy and safety of CXRs performed after cardiac surgery for specified indications only. METHODS In this observational cohort study, we prospectively included all patients who underwent conventional major cardiac surgery by median sternotomy in the year 2012. On-demand CXRs could be obtained during the first postoperative period for specified indications only. A routine control CXR was performed on the morning of the first postoperative day for all patients who had not undergone a CXR before that time. The diagnostic and therapeutic efficacy values were calculated for all CXRs. Differences were tested using Fishers exact test or χ(2) analysis. RESULTS A total of 1102 consecutive cardiac surgery patients were included in this study. The diagnostic efficacy of CXRs for major abnormalities was higher for the postoperative on-demand CXRs (n = 301; 27%) than for the routine CXRs taken the morning after surgery (n = 801; 73%) (6.6% vs 2.7%, P = .004). The therapeutic efficacy was higher for the on-demand CXRs, whereas the need for intervention after the next-morning, routine CXRs was limited to 5 patients (4.0% vs 0.6%, P < .001). None of these patients experienced a major adverse event. CONCLUSIONS Defining clear indications for selective CXRs after cardiac surgery is effective and seems to be safe. This approach may significantly reduce the total number of CXRs performed, and will increase their efficacy.

Purpura in a Patient Receiving Vancomycin: A Leukoclastic Vasculitis?

restriction in dose and time of administration. Exclusion criteria: duplicate publications, non-human experimental studies, and lack of data (either outcome data or side effects). Among 25 randomized controlled trials, all but 1 author16 administered orphine in the intrathecal space while 3 authors added cloniine to morphine, and 1 author administered bupivacaine nly.16 If our meta-analysis was performed correctly, the Lee et al paper was the only randomized trial ever published on the use of local anesthetics on top of a general anesthesia in adult cardiac surgery. We included it according to the predefined inclusion/exclusion criteria, and still think this was methodologically correct, the only imperfection being the use of the term “analgesia” instead of “anesthesia”: this was done to simplify the paper and the message that all the patients included in the 25 trials received a general anesthesia, with or without spinal “analgesia.” We agree with Scott that the paper of Lee et al16 has extraorinary peculiarities and that it was the first and last trial to study uch a strategy. Unfortunately the paper, published in 2003, ncluded only 19 patients per group and reported no clinically elevant outcome. We hope that many similar papers will ollow and that they will report clinically relevant outcomes ccording to the intention-to-treat analysis and long-term folow-up. If they are large enough, they will give to the scientific ommunity interesting hints; if they are small, they will be ncluded in updated meta-analysis, and it will be possible to ifferentiate between “opioid spinal analgesia” and “local ansthetic spinal anesthesia.” The clinical message of our meta-analysis remains strong. If onors and researchers have money and time to spend and want o improve clinically relevant endpoints in cardiac surgery, pinal anesthesia is not among the priorities for the time beng,14 while epidural analgesia4 and other drugs/techniques represent strong priorities.2,6,9 One of the possible explanations is the one suggested by Scott, since most authors of the “negative spinal meta-analysis”17 administered opioids, and most authors of a recent “postive epidural meta-analysis”4 administered local anesthetics. When performing neuraxial anesthesia, please administer loal anesthetics. Supplementary adjuvants should have additive ffects to those of the local anesthetic not antagonistic.”

Does a Platelet Transfusion Independently Affect Bleeding and Adverse Outcomes in Cardiac Surgery

Background: Conflicting results have been reported concerning the effect of platelet transfusion on several outcomes. The aim of this study was to assess the independent effect of a single early intraoperative platelet transfusion on bleeding and adverse outcomes in cardiac surgery patients. Methods: For this observational study, 23,860 cardiac surgery patients were analyzed. Patients who received one early (shortly after cardiopulmonary bypass while still in the operating room) platelet transfusion, and no other transfusions, were defined as the intervention group. By matching the intervention group 1:3 to patients who received no early transfusion with most comparable propensity scores, the reference group was identified. Results: The intervention group comprised 169 patients and the reference group 507. No difference between the groups was observed concerning reinterventions, thromboembolic complications, infections, organ failure, and mortality. However, patients in the intervention group experienced less blood loss and required vasoactive medication 139 of 169 (82%) versus 370 of 507 (74%; odds ratio, 1.65; 95% CI, 1.05 to 2.58), prolonged mechanical ventilation 92 of 169 (54%) versus 226 of 507 (45%; odds ratio, 1.47; 94% CI, 1.03 to 2.11), prolonged intensive care 95 of 169 (56%) versus 240 of 507 (46%; odds ratio, 1.49; 95% CI, 1.04 to 2.12), erythrocytes 75 of 169 (44%) versus 145 of 507 (34%; odds ratio, 1.55; 95% CI, 1.08 to 2.23), plasma 29 of 169 (17%) versus 23 of 507 (7.3%; odds ratio, 2.63; 95% CI, 1.50–4.63), and platelets 72 of 169 (43%) versus 25 of 507 (4.3%; odds ratio, 16.4; 95% CI, 9.3–28.9) more often compared to the reference group. Conclusions: In this retrospective analysis, cardiac surgery patients receiving platelet transfusion in the operating room experienced less blood loss and more often required vasoactive medication, prolonged ventilation, prolonged intensive care, and blood products postoperatively. However, early platelet transfusion was not associated with reinterventions, thromboembolic complications, infections, organ failure, or mortality.

The value of routine chest radiographs after minimally invasive cardiac surgery: an observational cohort study

BackgroundChest radiographs (CXRs) are obtained frequently in postoperative cardiac surgery patients. The diagnostic and therapeutic efficacy of routine CXRs is known to be low and the discussion regarding the safety of abandoning these CXRs after cardiac surgery is still ongoing. We investigated the value of routine CXRs directly after minimally invasive cardiac surgery.MethodsWe prospectively included all patients who underwent minimally invasive cardiac surgery by port access, ministernotomy or bilateral video-assisted thoracoscopy (VATS) in the year 2012. A direct postoperative CXR was performed on all patients at ICU arrival. All CXR findings were noted, including whether they led to an intervention or not. The results were compared to the postoperative CXR results in patients who underwent conventional cardiac surgery by full median sternotomy over the same period.Main resultsA total of 249 consecutive patients were included. Most of these patients underwent valve surgery, rhythm surgery or a combination of both. The diagnostic efficacy for minor findings was highest in the port access and bilateral VATS groups (56% and 63% versus 28% and 45%) (p < 0.005). The diagnostic efficacy for major findings was also higher in these groups (8.9% and 11% versus 4.3% and 3.8%) (p = 0.010). The need for an intervention was most common after minimally invasive surgery by port access, although this difference was not statistically significant (p = 0.056).ConclusionsThe diagnostic efficacy of routine CXRs performed after minimally invasive cardiac surgery by port access or bilateral VATS is higher than the efficacy of CXRs performed after conventional cardiac surgery. A routine CXR after these procedures should still be considered.

Effectiveness of pericardial lavage with or without tranexamic acid in cardiac surgery patients receiving intravenous tranexamic acid: a randomized controlled trial

OBJECTIVES Pericardial lavage with saline, with or without tranexamic acid (TA), is still not evidence-based within current clinical practice as a part of a blood conservation strategy in cardiac surgery patients receiving intravenous TA administration. The objective was to determine whether intravenous TA combined with pericardial lavage with saline, with or without TA, reduces blood loss by 25% after cardiac surgery measured in the first 12 h postoperatively. METHODS In this single-centre, randomized controlled, multiple-armed, parallel study, individual patients were randomly assigned to receive either topical administration of 2 g TA diluted in 200 ml of saline (TA group), 200 ml of saline (placebo group) or no topical administration at all (control group). Eligible participants were all adults aged 18 or older and scheduled for elective cardiac surgery on cardiopulmonary bypass. All patients received 2 g TA intravenously before sternal incision and 2 g TA after cardiopulmonary bypass. The main outcome measure was the 12-h postoperative blood loss. RESULTS In total, 739 individuals were analysed according to intention-to-treat analyses (TA group, n = 245 patients; placebo group, n = 249 patients; control group, n = 245 patients). There was no difference in the median 12-h postoperative blood loss between the three groups [TA group, 290 (IQR 190-430) ml; placebo group, 290 (IQR 210-440) ml; control group, 300 (IQR 190-450) ml, P= 0.759]. CONCLUSIONS Pericardial lavage, with or without TA, does not result in a statistically significant difference in the 12-h postoperative blood loss in cardiac surgery patients receiving intravenous TA administration. Pericardial lavage with saline, with or without TA, should not be a part of a blood conservation strategy.

Minimal Invasive Mitral Valve Surgery with Endo-Aortic Balloon Requires Cerebral Monitoring

After induction of anesthesia, an extra right radial artery catheter and cerebral oximetry were placed for minimally invasive mitral valve surgery. An anterolateral minithoracotomy, endoaortic balloon, and left atriotomy allowed visualization of the mitral valve. During the procedure, we observed a drop of the right cerebral oximetry saturation without a drop in right radial artery pressure. We suspected an aberrant right subclavian artery. After the endoaortic balloon was repositioned, right cerebral oximetry recovered. A postoperative computed tomography scan revealed an aberrant right subclavian artery. In this case, bilateral upper extremity arterial pressure monitoring would not have detected cerebral hypoperfusion.