S.H. Bailey

Preoperative statin is associated with decreased operative mortality in high risk coronary artery bypass patients

BackgroundStatins are widely prescribed to patients with atherosclerosis. A retrospective database analysis was used to examine the role of preoperative statin use in hospital mortality, for patients undergoing isolated coronary artery bypass grafting (CABG.)MethodsThe study population comprised 2377 patients who had isolated CABG at Allegheny General Hospital between 2000 and 2004. Mean age of the patients was 65 ± 11 years (range 27 to 92 years). 1594 (67%) were male, 5% had previous open heart procedures, and 4% had emergency surgery. 1004 patients (42%) were being treated with a statin at the time of admission. Univariate, bivariate (Chi2, Fishers Exact and Students t-tests) and multivariate (stepwise linear regression) analyses were used to evaluate the association of statin use with mortality following CABG.ResultsAnnual prevalence of preoperative statin use was similar over the study period and averaged 40%. Preoperative clinical risk assessment demonstrated a 2% risk of mortality in both the statin and non-statin groups. Operative mortality was 2.4% for all patients, 1.7% for statin users and 2.8% for non-statin users (p < 0.07). Using multivariate analysis, lack of statin use was found to be an independent predictor of mortality in high-risk patients (n = 245, 12.9% vs. 5.6%, p < 0.05).ConclusionsBetween 2000 and 2004 less than 50% of patients at this institution were receiving statins before admission for isolated CABG. A retrospective analysis of this cohort provides evidence that preoperative statin use is associated with lower operative mortality in high-risk patients.

Salvage Peripheral Extracorporeal Membrane Oxygenation Using Cobe Revolution® Centrifugal Pump as a Bridge to Decision for Acute Refractory Cardiogenic Shock

Abstract  Objectives: Acute refractory cardiogenic shock with early multisystem organ failure has a poor outcome without mechanical circulatory support. We review our experience with emergent peripheral cardiopulmonary support as a bridge to decision in these patients. Methods: A retrospective review from January 2009 through December 2010 was conducted of 26 consecutive adult patients at a single institution with acute refractory cardiogenic shock who underwent salvage peripheral cardiopulmonary support. Results: There were 18 men and 8 women with a mean age of 54 years (range 18 to 76). Indications for support: acute myocardial infarction (n = 16), decompensated chronic heart failure (n = 2), refractory arrhythmic arrest (n = 3), acute valvular pathology (n = 4), and unknown (n = 1). Patients with primary postcardiotomy shock were excluded. Median duration of support was 3 days (range 1 to 14). Decisions included: withdraw of support (n = 4), recovery (n = 5), and bridge to a procedure (n = 17). The procedures were percutaneous coronary intervention (n = 4), left ventricular assist device (n = 9), heart transplantation (n = 1), and miscellaneous cardiac surgery (n = 3). Overall survival to discharge was 65%. In the recovery and bridge to a procedure group, 78% were discharged from the hospital and survival at three months was 72%. Conclusions: Salvage peripheral cardiopulmonary support is a useful tool to rapidly stabilize acute refractory cardiogenic shock permitting an assessment of neurologic and end‐organ viability. (J Card Surg 2012;27:521‐527)

Strategies and Outcomes of Cardiac Surgery in Jehovah's Witnesses

Abstract  Background: Jehovahs Witnesses (JW) are a Christian faith, with an estimated 1.1 million members in the United States, well recognized for their refusal of blood and blood products. JW may not be considered for cardiac surgery due to perceived higher risks of morbidity and mortality. This study reviews our contemporary strategies and experience with JW undergoing routine and complex cardiac surgery. Methods: From November 2001 to April 2010, 40 JW were referred for cardiac surgery at a single quaternary referral institution. A retrospective analysis of demographic data, perioperative management, and clinical outcomes was examined. Published validated clinical risk calculator and model for prediction of transfusion were used to identify high‐risk patients (risk of mortality >6% or probability of transfusion >0.80). Results: The mean age was 70 (± 9.5) years with 21 men and 19 women. Patients were classified as high risk (45%, n = 18) and low risk (55%, n = 22) with demographics and comorbidities listed in Table 2. Operative procedures included: isolated coronary artery bypass grafting (CABG) (n = 19), isolated valve replacement/repair (n = 7), valve/CABG (n = 7), reoperative valve replacement (n = 4), reoperative CABG (n = 2), valve/ascending aorta replacement (n = 1), and CABG/ascending aorta replacement (n = 1). All JW were evaluated by The Department of Bloodless Medicine to individually define acceptable blood management strategies. The mean preoperative hemoglobin was 14.1 g/dL (±1.6). Overall mortality was 5% (n = 2) all of which were in the high‐risk group. Discussion: Using a multidisciplinary approach to blood management, JW can safely undergo routine and complex cardiac surgery with minimal morbidity and mortality. (J Card Surg 2011;26:135‐143)

Thoracic endovascular aortic repair of an aberrant right subclavian artery: technique and long-term outcome.

Abstract  Background: Aberrant right subclavian artery (ARSA) is the most common congenital arch anomaly, which can be complicated by aneursymal dilation at its ostium. We describe a successful repair of an ARSA with a three‐stage operative procedure using a left carotid to subclavian bypass, coiling of the ARSA, and thoracic endovascular aortic repair with long‐term clinical and radiographic follow‐up. (J Card Surg 2010;25:390‐393)

Temporary Mechanical Circulatory Support for Takotsubo Cardiomyopathy Secondary to Primary Mediastinal B‐Cell Lymphoma

Abstract  Background: Left heart mechanical circulatory support (MCS) through the left chest via the pulmonary vein and descending thoracic aorta is a good option for patients with an inaccessible anterior mediastinum and/or poor peripheral access. Materials and Methods: We report the case of a 19‐year‐old small female with a newly discovered bulky primary mediastinal diffuse large B‐cell lymphoma (PMBL) who developed refractory inverted Takotsubo cardiomyopathy (TC) with cardiogenic shock. Results: Temporary MCS was implemented in order to stabilize the patient and proceed with a chemotherapy treatment. Given the patients oncologic “frozen” mediastinum and the presence of poor peripheral arterial access, the left heart temporary MCS was successfully implanted through a left mini‐thoracotomy via the left inferior pulmonary vein and descending thoracic aorta. Conclusions: This is the first report of temporary MCS to treat inverted TC and diffuse PMBL. (J Card Surg 2012;27:119–121)

Severe Acute Traumatic Mitral Regurgitation, Cardiogenic Shock Secondary to Embolized Polymethylmethracrylate Cement Foreign Body After a Percutaneous Vertebroplasty

We report the case of a 61-year-old woman with acute decompensated heart failure secondary to acute traumatic mitral regurgitation, resulting from polymethylmethacrylate cement found in the left ventricle less than 24 hours after fluoroscopic percutaneous vertebroplasty. The patient had a history of ovarian cancer and had undergone treatment for symptomatic osteoporotic compression fractures of the vertebrae (T11, L1, and L3). The patient underwent a successful emergency open-heart operation, mitral valve replacement, closure of an atrial septal defect, and video-assisted removal of the cement foreign body from the left ventricle. The patient was later discharged with a good outcome.

Combined carotid endarterectomy and transcatheter aortic valve replacement: Technique and outcomes

Stroke and transient ischemic attack after transcatheter aortic valve replacement results in significantly higher morbidity and mortality. Severe carotid artery disease may be a contributing factor to this increased risk. We report our technique and outcomes of combined carotid endarterectomy (CEA) with transcatheter aortic valve replacement (TAVR).

Transapical valve-in-valve replacement of a stenosed prosthetic mitral valve in a critically ill patient with cardiogenic shock: a case report

The burden of managing dysfunctional mitral prosthetic valve disease in the elderly population is increasing for those who cannot tolerate a redo sternotomy along with their multiple comorbid conditions. We report a critically ill elderly patient with a high surgical risk, multiple comorbid conditions, longstanding chronic lung disease, hepatic dysfunction, coagulopathy, acute kidney injury, fluid overload and presenting with cardiogenic shock who was initially rescued with veno-arterial extracorporeal membrane oxygenation and then underwent successful transapical mitral valve-invalve replacement. She survived the procedure and was successfully extubated in the ICU on postoperative day 2. She died on day 5 due to a suspected thrombotic state.

Catch 22: a case of incessant ventricular tachycardia post-left ventricular assist device resulting in right ventricular failure, left ventricular cavity obliteration and failure of endocardial ventricular tachycardia ablation

Ventricular tachycardia (VT) in the setting of left ventricular assist device (LVAD) therapy has been well described. We present a case of incessant ventricular tachycardia resulting in severe right ventricular (RV) failure and subsequent left ventricular (LV) cavity obliteration, which in turn diminished the feasibility of initial attempt at VT ablation.