Rolf Busund

Resuscitation from accidental hypothermia of 13·7°C with circulatory arrest

Summary Summary In a victim of very deep accidental hypothermia, 9 h of resuscitation and stabilisation led to good physical and mental recovery. This potential outcome should be borne in mind for all such victims.

Transcatheter aortic-valve implantation for aortic stenosis.

BACKGROUND Short-term results are presented from our first year of experience with transcatheter aortic-valve implantation [corrected] (TAVI) at the University Hospital of North Norway. MATERIALS AND METHODS TAVI was used to treat 25 patients with aortic stenosis [corrected] from September 2008 to August 2009. 25 patients operated with conventional aortic valve replacement (AVR) served as controls. RESULTS The TAVI group had a significantly higher EuroSCORE (p < 0.001) than the AVR group. No patients in the TAVI group were treated in the intensive care unit while those in the AVR group received 38 days of intensive care in total. The TAVI group had shorter operating times (p < 0.001), larger mean valve sizes (p < 0.001) and significantly fewer postoperative transfusions (p < 0.001) than the ACR group. Peri-operative stroke and myocardial infarction did not occur in the TAVI group while there was one incidence of stroke and one myocardial infarction in the AVR group. The postoperative transvalvular mean gradient decreased in both groups (p < 0.001) and was significantly lower in the TAVI group (p = 0.001). The NYHA class improved significantly in the TAVI group (p < 0.001). No patients needed implantation of a permanent pacemaker. 30-day mortality was four patients in the AVR group and one patient in the TAVI group. After discharge one patient died in each group. INTERPRETATION TAVI is safe and effective for selected patients with aortic stenosis [corrected] who are assessed as high risk for AVR. Long-term results are needed and will be decisive for use of this approach in the future.

Hypothermic cardiac arrest far away from the center providing rewarming with extracorporeal circulation

A 41-year-old man suffered hypothermic cardiac arrest after water immersion and was transported to our university hospital by ambulance helicopter for rewarming on cardiopulmonary bypass. He resumed spontaneous cardiac activity 6 h 52 min after cardiac arrest and recovered completely.

Early clinical outcome of aortic transcatheter valve-in-valve implantation in the Nordic countries.

OBJECTIVE Transcatheter valve-in-valve implantation has emerged as an option, in addition to reoperative surgical aortic valve replacement, to treat failed biologic heart valve substitutes. However, the clinical experience with this approach is still limited. We report the comprehensive experience of transcatheter valve-in-valve implantation in the Nordic countries from May 2008 to January 2012. METHODS A total of 45 transcatheter aortic valve-in-valve implantations were performed during the study period in 11 centers. The mean age of the patients was 80.6 years (range, 61-91), 26 were male and 19 were female, and the mean EuroSCORE, EuroSCORE II, and Society of Thoracic Surgeons score was 35.4, 16.3, and 14.6, respectively. The type of failure was stenosis and combined in 58% (mean and peak aortic valve gradient, 77 and 45 mm Hg, respectively) and regurgitation in 42% of cases. The SAPIEN/XT (Edwards LifeSciences, Irvine, Calif) and CoreValve (Medtronic Inc, Minneapolis, Minn) system was used in 33 and 12 cases, respectively. The access route was transapical in 25, transfemoral in 17, transaortic in 2, and subclavian in 1 case. The mean follow-up was 14.4 months. The periprocedural and postoperative outcomes were assessed using the Valve Academic Research Consortium criteria. RESULTS No intraprocedural mortality occurred. The technical success rate was 95.6% (1 second valve implantation, 1 conversion to open surgery). The all-cause 30-day mortality was 4.4% (1 cardiac-related and 1 aspiration pneumonia). The major complications within 30 days included stroke in 2.2%, periprocedural myocardial infarction in 4.4%, and major vascular complication in 2.2% of patients. At 1 month, all but 1 patient had either no or mild paravalvular leakage, with a mean and peak valve gradient of 17 mm Hg (range, 4-38) and 30 mm Hg (range, 7-68), respectively. The mean gradient was greater than 20 mm Hg in 17% of patients and remained unchanged at 12 months. The 1-year survival was 88.1%. CONCLUSIONS Transcatheter valve-in-valve implantation is widely performed, albeit in small numbers, in most centers in the Nordic countries. The short-term results were excellent in this high-risk patient population, demonstrating a low incidence of device- or procedure-related complications. However, a considerable number of patients were left with suboptimal systolic valve performance with unknown long-term effects, warranting close surveillance after transcatheter valve-in-valve implantation.

Cardioprotective effect of pretreatment with b-glucan in coronary artery bypass grafting

Background. β-glucan pretreatment has been shown to attenuate inflammatory response and to protect against ischemia-reperfusion injury in animal studies. The aims of the present study were to examine the safety of pretreatment with β-1,3/1,6-glucan in patients scheduled for coronary artery bypass grafting (CABG), and to investigate whether β-1,3/1,6-glucan pretreatment could suppress inflammatory response and protect against ischemia-reperfusion injury following CABG. Methods. Twenty one patients scheduled for CABG were assigned to oral β-1,3/1,6-glucan 700 mg (Group 1) or 1 400 mg (Group 2) five consecutive days before surgery and were compared with a control group (Group 3). Blood samples were drawn preoperatively and on the first, third and fifth postoperative day for analysis of acute-phase reactants, hematology, cytokines and myocardial enzymes. Results. The study drug was well tolerated. Creatine kinase isoenzyme MB was significantly lower in Group 2 compared with controls on the first postoperative day (p = 0.028). Mean change in cardiac troponin T was lower in Group 2 compared with controls (p = 0.028). Conclusions. β-1,3/1,6-glucan pretreatment is safe in patients undergoing CABG and may protect against ischemia reperfusion injury following CABG.

Increased Risk of Transmission of Hepatitis C in Open Heart Surgery Compared With Vascular and Pulmonary Surgery

BACKGROUND We report a case of patient-to-surgeon transmission of hepatitis C virus (HCV), and the subsequent transmission of HCV to surgical patients. METHODS In 2007, a cardiac surgeon tested positive for hepatitis C. A complete look-back investigation was initiated that involved screening of all patients on the surgeons operating lists between September 2004 and April 2007. Genotyping and phylogenetic analyses were performed where HCV RNA was detected. RESULTS Of the 499 patients invited to HCV testing, 431 responded, 13 of whom were found anti-HCV positive. One patient, who had surgery in August 2005, was found most likely to be the source of transmission to the surgeon. Of the 270 patients who had surgery after this incident, 10 became infected, giving an estimated rate of transmission of 3.7%. The HCV polymerase chain reaction positive samples were found to be the same genotype 1a strain by phylogenetic analyses. All the 10 subsequently infected patients had undergone open heart surgery, whereas none of the 103 noncardiac patients became infected, giving an estimated risk of transmission during open heart surgery of 6.0% (95% confidence interval [3.3% to 10.7%]). CONCLUSIONS The transmission rate from an HCV positive surgeon to patients in a cardiothoracic setting was higher than previously reported and significantly higher during open heart surgery compared with vascular and pulmonary surgery. These results indicate the need for unequivocal routines for testing and handling of HCV positive health care workers and patients.