Patrick Ergina

Cardiac Surgery in Octogenarians: Long-Term Survival, Functional Status, Living Arrangements, and Leisure Activities

BACKGROUND A prospective study of survival, functional outcome, living arrangements, daily activities and leisure engagements among octogenarians up to 5 years after cardiac surgery was performed. METHODS The study consisted of a cohort of 300 consecutive octogenarians with three interviews made at 6-month intervals for a total of 593 postoperative interviews. Functional outcomes were measured using the Barthel index and Karnofsky performance scores and divided into autonomous, semiautonomous, or dependent. Living arrangements and leisure activities within the social, physical, cognitive, and creative domains were recorded in an open-ended questionnaire. RESULTS There were 150 men and 150 women with a mean age 82.6 years. The 30-day survival was 84.3%. Actuarial survival at 1, 3, and 5 years was 76.6%, 66.6%, and 57.8%, respectively. Among the survivors at the first interview, 2.2 years postoperatively, there were 63.9% autonomous, 31.7% semiautonomous, and 4.3% dependent patients versus at the last interview, 3.6 years postoperatively, in which there were 64.9% autonomous, 28.1% semiautonomous, and 9.2% dependent. At the first interview, 76.4% were at home, 19.2 % in a residence, and 4.3% in a supervised setting. At the third interview, 71.8% were at home, 21.2% in a residence, and 6.9% in a supervised setting. Nearly all patients were involved in leisure activities in the social (98.9%), cognitive (98.4%), and physical (93.1%) domains. At the end of the last interview, activities within the social and cognitive domains were maintained with a small decrease in the physical domain. CONCLUSIONS Surviving octogenarians remain at home, function independently, and engage in regular leisure activities years after cardiac surgery. This information might help physicians and surgeons regarding long-term outcome of open cardiac surgery in octogenarians.

Impact of transfusion of mediastinal shed blood on serum levels of cardiac enzymes

BACKGROUND Infusion of shed mediastinal blood using an autotransfusion system is a widely applied technique of blood conservation in cardiac surgery. Serial determinations of serum creatine kinase (CK), its MB isoenzyme (CK-MB), and lactate hydrogenase (LDH) levels have been used to monitor perioperative myocardial injury. We investigated the impact of postoperative autotransfused blood infusion on serum levels of these enzymes. METHODS We performed a retrospective analysis of postoperative serum CK, CK-MB, and LDH levels of 300 patients who had elective uncomplicated aortocoronary bypass grafting. Shed mediastinal blood samples from 26 patients were analyzed for CK, CK-MB (enzymatic activity and mass), and LDH levels before infusion. RESULTS High postoperative serum levels of CK and LDH were observed after infusion of autotransfused blood. Shed mediastinal blood contained extremely high levels of these enzymes, particularly from patients who had internal mammary artery dissection. There was a strong correlation (r = 0.96) between measured CK-MB enzyme activities and those calculated from the CK-MB mass units. CONCLUSIONS Infusion of autotransfused blood containing high concentrations of CK and LDH results in elevated serum levels of these enzymes. Hemolysis, frequently present in shed blood, does not interfere with the routine biochemical assays for CK and CK-MB enzyme activities. Caution should be taken when postoperative cardiac enzyme levels are used to determine myocardial injury after aortocoronary bypass grafting if autotransfusion is used as a method of blood conservation.

Reinfusion of Mediastinal Blood in CABG Patients: Impact on Homologous Transfusions and Rate of Re‐exploration

Abstract Background: Reinfusion of mediastinal shed blood after cardiac surgery has been used in some centers to reduce exposure to homologous blood transfusions. The method has not been widely applied mostly because some studies have failed to demonstrate a significant benefit. Methods: A group of 675 consecutive patients undergoing first‐time, isolated coronary artery bypass surgery (CABG) was studied. Prospective data was collected on the first 375 patients receiving autotransfusion (ATS) of mediastinal shed blood. The charts of 338 patients immediately preceding the institution of the ATS program at our institution (NO ATS group) were retrospectively reviewed. Transfusion of homologous blood products and rate of re‐exploration for bleeding were closely monitored. Results: The two groups were identical. The net blood loss was significantly less in the ATS group than in the NO ATS group (1013 ± 431 cc vs 1371 ± 631 cc, p < 0.0001). Rate of exploration for postoperative bleeding was 1.5% in the ATS group and 5.0% in the NO ATS group (p < 0.01). In the ATS group, 51.9% of patients were not exposed to any homologous blood product (vs 17.8% in the NO ATS group, p < 0.0001). The ATS patients received on the average 2.9 ± 7.2 units of blood products versus 6.4 ± 9.7 units in the NO ATS group (p < 0.0001). Conclusion: Reinfusion of mediastinal shed blood significantly reduces exposure to homologous blood transfusions and rate of re‐exploration. The ATS system reduces the number of re‐explorations for coagulopathy‐related postoperative hemorrhage.

Veno-Atrial Bypass for the Operative Treatment of Septic Gas Gangrene Secondary to Delayed Hepatic Artery Thrombosis

The occurrence of late hepatic artery thrombosis after orthotopic liver transplantation can result in gas gangrene of the graft. This clinical scenario has the potential to be rapidly fatal as a result of fulminant hepatic failure, sepsis and multiple‐organ‐failure syndrome. Emergency operative intervention is indicated to remove the septic source and replace the failed liver. In this report, both cases demonstrated rapid deterioration within 24 h from the onset of symptoms, in spite of maximum supportive care. Intra‐operative handling of the gangrenous graft resulted in hemodynamic instability and a technically unfeasible hepatectomy. The use of extra‐corporeal veno‐atrial bypass, by isolating the septic source, allowed for graft hepatectomy and successful re‐transplantation in the second of these reported cases.

Chest wall infarction following bilateral internal mammary to coronary arterial bypass in a patient with a thoracoabdominal aneurysm.

Abstract A 69‐year‐old man with severe peripheral vascular disease and a known thora‐coabdominal aortic aneurysm underwent bilateral internal mammary artery (BIMA) to coronary artery bypass grafting and aortic hemiarch replacement. He immediately thereafter developed massive chest wall ischemia and infarction with a severe metabolic acidosis, and subsequently died. Chest wall infarction following BIMA harvesting has not been previously described. Cautious use of internal mammary arterial grafting may be in order in the severe vasculopath with significant thrombo‐occlusive thoracoabdominal aortic disease.

Total parenteral nutrition did not reduce major complications of nonemergent major abdominal or thoracic surgery in malnourished patients

Source Citation The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative total parenteral nutrition in surgical patients. N Engl J Med. 1991 Aug 22;325:525-32.

Two cases of heart-liver transplant on cardiopulmonary bypass

CLINICAL FEATURES: Consent for disclosure of these cases was obtained from both patients. Patient 1 was a 53 yearold man with familial hypertrophic cardiomyopathy who developed cirrhosis secondary to right ventricular failure. His past medical history included atrial fibrillation with sino-atrial ablation and pacemaker placement. He had normal LV function with severe RV diastolic dysfunction and congestive heart failure (NYHA class IV). Patient 2 was a 57 year-old man with hypertrophic restrictive cardiomyopathy with reduced LV function of 25-30% (NYHA class III heart failure), congestive hepatitis with cirrhosis, atrial fibrillation, ICD, chronic renal failure and mild COPD. Both patients were taking coumadin.