Robert Lancey

Arrhythmias and conduction disturbances after coronary artery bypass graft surgery: Epidemiology, management, and prognosis

CABG is associated with many perioperative complications, including supraventricular and ventricular arrhythmias and conduction disturbances. Atrial fibrillation occurs in < or = 40% of patients after CABG and is especially common in older patients. Although it is often benign and self-limited, it can lead to complications such as stroke. Treatment consists primarily of control of the ventricular response rate; in some cases, antiarrhythmic drugs or electrical cardioversion are needed. Anticoagulation should be considered in appropriate cases of persistent (48 to 72 hours) atrial fibrillation after initial treatment. Prophylaxis, especially with beta-blocking agents, seems to be effective and should be considered in appropriate cases. Simple ventricular arrhythmias are common after CABG and do not affect the patients prognosis; however, sustained VT/VF occur infrequently (< 2% of patients) and carry a high mortality rate. Treatment is aimed at correcting precipitating factors (e.g., myocardial ischemia). Electrophysiologically guided drug therapy and implantation of an ICD should be considered in appropriate cases for patients who survive the initial events. Transient minor conduction disturbances are common after CABG; in some patients persistent AV block and sinus node dysfunction develop and may require treatment with permanent pacemaker.

Reduction of bleeding after heart operations through the prophylactic use of epsilon-aminocaproic acid

UNLABELLED Excessive postoperative bleeding after heart operations continues to be a source of morbidity. This prospective double-blind study evaluated epsilon-aminocaproic acid as an agent to reduce postoperative bleeding and investigated its mode of action. One hundred three patients were randomly assigned to receive either 30 gm epsilon-aminocaproic acid (51 patients) or an equivalent volume of placebo (52 patients). In a subset of these patients (14 epsilon-aminocaproic acid, 12 placebo), tests of platelet function and fibrinolysis were performed. RESULTS By multivariate analysis, three factors were associated with decreased blood loss in the first 24 hours after operation: epsilon-aminocaproic acid versus placebo (647 ml versus 839 ml, p = 0.004), surgeon 1 versus all other surgeons (582 ml versus 978 ml, p = 0.002), and no intraaortic balloon versus intraaortic balloon pump use (664 ml versus 1410 ml, p = 0.02). No significant differences in platelet function could be demonstrated between the two groups. Inhibited fibrinolysis, as reflected by less depression of the euglobulin clot lysis and no rise in D-dimer levels, was significant in the epsilon-aminocaproic acid group compared with the placebo group. CONCLUSION The intraoperative use of epsilon-aminocaproic acid reduces postoperative cardiac surgical bleeding.

Effectiveness of bi-atrial pacing for reducing atrial fibrillation after coronary artery bypass graft surgery.

Atrial fibrillation (AF) is common after cardiac surgery and adds significant cost and morbidity. The use of prophylactic pacing strategies to prevent post-operative AF has been controversial. We previously performed a pilot study which suggested that the combination of beta-blockers and bi-atrial pacing (BAP) may reduce AF after cardiac surgery.We prospectively randomized 118 patients to continuous BAP for up to 96 hours post-operatively versus standard therapy. All patients were treated with beta-blockers as tolerated. Patients were paced in the AAI mode at a rate of 100 pulses per minute. The primary endpoint of the study was the occurrence of sustained AF (>10 minutes).There was a significant reduction in the incidence of AF in the BAP group among patients undergoing coronary artery bypass graft surgery with or without aortic valve replacement (35% vs. 19% AF; OR=0.38, 95% CI 0.15, 0.93; p <0.05). Including patients undergoing isolated aortic valve surgery (n=7), there remained a strong trend toward a reduction of AF with pacing (no atrial pacing [NAP] vs. BAP; 35% vs. 21% AF; OR=0.48, 95% CI 0.21, 1.11; p=0.08). Patients age 70 or greater benefited most from pacing (NAP vs. BAP; 55 vs. 25% AF; p<0.05), while those less than 70 years of age did not (17 vs. 18% p=NS). There was a significant reduction in the amount of time spent in the intensive care unit among patients receiving BAP (50±40 vs. 37±25[emsp4 ]h; p<0.05).BAP together with beta-blockade after coronary artery bypass graft surgery reduces the incidence of post-operative atrial AF. Elderly patients (age 70 or greater) appear to benefit most, and may be a group to whom this therapy should be targeted.

Staged laparoscopic splenectomy and valve replacement in splenic abscess and infective endocarditis

Splenic abscess is a rare clinical entity that is most commonly associated with infective endocarditis. Valve replacement in the setting of an unaddressed splenic abscess is associated with a high incidence of prosthetic valve infection and death. We describe 2 patients with infective endocarditis and splenic abscess treated by laparoscopic splenectomy followed by valve replacement.

Uniform standards do not apply to readmission following coronary artery bypass surgery: a multi-institutional study.

OBJECTIVES Reducing hospital readmissions is a national priority, with coronary artery bypass graft (CABG) surgery slated for upcoming reimbursement decisions. Clear understanding of the elements associated with readmissions is essential for developing a coherent prevention strategy. Patterns of readmission vary considerably based on diagnosis. We therefore sought to clarify the factors most clearly associated with 30-day readmission following CABG surgery in an academically affiliated community hospital network. METHODS All patients undergoing isolated CABG in an 11-hospital network from 2007 to 2011 were entered into a Society of Thoracic Surgeons (STS) compliant registry that tracks hospital readmission within 30 days of surgery. Data were split at random into training and validation groups that were used to create and validate a logistic regression model of pre-, intra-, and postoperative factors associated with readmission. Subanalyses included development of logistic models predicting readmission for the 2 largest institutions individually, and relatedness of readmission to CABG procedure. RESULTS The readmission rate for the entire 4861 patient group was 9.2% and varied between hospitals from 6.1% to 18.0%. Factors associated with readmission were moderate chronic obstructed pulmonary disease (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.04-3.14; P = .036), cerebrovascular disease (OR, 1.56; 95% CI, 1.09-2.24; P = .016), diabetes (OR, 1.44; 95% CI, 1.08-1.93; P = .014), congestive heart failure (OR, 2.12; 95% CI, 1.23-3.66; P = .007), intra-aortic balloon pump (OR, 0.40; 95% CI, 0.19-0.83; P = .015), and use of blood products (OR, 1.76; 95% CI, 1.31-2.37; P = .0002). Although the c statistic for the training model (n = 2341) was 0.643, when applied to the validation dataset (n = 2520) the area under the receiver operating curve was reduced to 0.57. Separate analyses of factors for the 2 largest hospitals revealed marked differences, with only body mass index (OR, 1.08; 95% CI, 1.04-1.12; P = .0001) significantly associated with readmission at 1 hospital, and discharge to extended care (OR, 2.11; 95% CI, 1.02-4.33; P = .043) and renal failure (OR, 2.64; 95% CI, 1.21-5.76; P = .0149) significant at the other hospital. Most readmissions (60.8%) occurred within 10 days of discharge. Nearly one-third (31.3%) were categorized as unlikely to be CABG-related. The mean number of days from surgery to readmission was less for readmissions clearly related to CABG (15.5 ± 6.4 days), compared with those unlikely to be CABG-related (17.4 ± 7.0 days) (P = .05). CONCLUSIONS Analysis of CABG readmission data from a network of community hospitals that vary in size and patient demographic characteristics suggests that there are many nonclinical factors influencing readmission; readmission rates and associated risk factors may vary considerably between centers; earlier readmissions are more likely to be procedure-related than patient-related; and therefore, considerable caution should be exercised in attempting to apply uniform standards or strategies to address post-CABG readmission.

Simultaneous repair of multiple traumatic aortic tears

A 34-year-old man suffered simultaneous tears of his distal ascending and mid-descending thoracic aorta secondary to blunt trauma. Repairs of both injuries were performed via a median sternotomy approach followed by a left lateral thoracotomy using two separate methods of cardiopulmonary bypass.