Journal of Cardiothoracic and Vascular Anesthesia - Articles in Press

Surgical Management of Ischemic Mitral Regurgitation: Relearning Our Lessons - Corrected Proof

Omair Shakil, Feroze Mahmood — 2012-05-18

ISCHEMIC MITRAL REGURGITATION (IMR) is a challenging clinical entity. When encountered as a sequel of subacute ischemia, it is characterized by mitral insufficiency despite anatomically normal-appearing leaflets. For anesthesiologists, the presentation is even more challenging when detected on a routine precardiopulmonary bypass transesophageal echocardiographic examination. As a consequence of chronic volume overload, the left ventricle undergoes adaptive changes in structure. These geometric changes in the left ventricle, which are characterized by papillary muscle displacement, tethering of the chordae, and mitral annular dilatation and flattening, have been implicated in the pathophysiology of IMR. The diagnosis of IMR indicates a worse prognosis and an increased risk of heart failure for patients with coronary artery disease.

How To Manage Aspirin Resistance Early After Coronary Artery Bypass Grafting - Corrected Proof

Mate Petricevic, Bojan Biocina, Sanja Konosic, Visnja Ivancan — 2012-05-18

We read with great interest the recently published study by Bednar et al. The study prospectively enrolled 30 patients undergoing coronary artery bypass graft (CABG) surgery to evaluate aspirin's effect on platelet function in the early postoperative phase. Aspirin (200 mg orally) was administered on the 1st postoperative day and continued at the same dose and time for days 1 through 5. Thirty percent of patients were diabetic. In our opinion, it would be interesting if the authors compared the proportion of patients with aspirin resistance (AR) with respect to the presence of diabetes as comorbidity. In our recent study, we analyzed the proportion of patients with AR both pre- and postoperatively. All patients received aspirin, 100 mg/d, until the day of surgery, and we observed 31.3% patients with AR preoperatively. Compared with the preoperative results, we detected higher values of the aggregation test triggered with arachidonic acid (ASPI) on postoperative day 4 (p = 0.04), with 46.5% of patients with AR despite a higher aspirin dose of 300 mg/d administered postoperatively. In addition, diabetic patients had a higher ASPI test value (p = 0.01) and a higher proportion of patients with AR compared with the nondiabetic subgroup (58.5% v 38%, p = 0.04). Using the same device for platelet function assessment, we also performed the adenosine diphosphate (ADP) test (the assessment of ADP receptors-mediated platelet activity, which is blocked by thienopyridines, such as clopidogrel). On postoperative day 4, we detected higher values of the ADP test (p = 0.002) compared with results obtained preoperatively. Thus, we believe that patients with AR detected in the early postoperative phase could benefit from a more aggressive antithrombotic treatment regimen, such as dual antiplatelet therapy with the addition of clopidogrel to aspirin therapy. Concerning clopidogrel administration, it is worthwhile to mention that a meta-analysis performed by Snoep et al showed an overall prevalence of 21% of a laboratory-defined clopidogrel low response. Currently, there is no established therapeutic approach for managing AR after CABG surgery that has been shown in large trials to have clinical benefit. In our opinion, antiplatelet therapy (APT) management in cases of AR should be tailored individually, with an aspirin dosage stepwise increase (up to 325 mg/d) and clopidogrel administration in cases of AR to high aspirin doses. Temporary AR, frequently observed in patients after CABG surgery, requires temporary APT adjustment. The duration and intensity of APT adjustment should be tailored according to drug-specific platelet function tests to minimize both ischemic and bleeding events. However, different APT approaches to patients with AR should be evaluated in large cohort randomized trials with an outcome evaluation of both ischemic and bleeding events. We congratulate the authors on their elegant and timely research.

Breakthroughs in Anticoagulation: Advent of the Oral Direct Factor Xa Inhibitors - Corrected Proof

John G.T. Augoustides — 2012-05-18

The oral direct factor Xa inhibitors include rivaroxaban and apixaban that recently have been evaluated comprehensively in multiple randomized clinical trials. Based on the efficacy and safety data from these trials, these novel anticoagulants are disseminating throughout clinical practice for thromboprophylaxis in major lower-extremity joint replacement, acute medical illness, atrial fibrillation, and acute coronary syndromes. The advantages of the xabans over vitamin K antagonists include no requirement for routine anticoagulation monitoring as well as a fast and reliable onset of action. The first perioperative limitation of the xabans is the lack of a routine coagulation test for monitoring their anticoagulant effect in scenarios, such as the timing of surgical procedures, the reversal of xaban-related bleeding, and the conduct of regional anesthesia. A second perioperative limitation is the lack of fully validated clinical reversal agents although prothrombin complex concentrate, recombinant factor VIIa, and factor X concentrate are options for xaban reversal in life-threatening bleeding scenarios. Given their clinical efficacy and advantages, further xabans are in clinical development, with edoxaban already in phase III clinical trials. Although the xabans have ushered in a new paradigm for clinical anticoagulation, further clinical trials are indicated to refine their clinical indications even further, such as anticoagulation for patients with mechanical heart valves.

Pharmacologic Management of Coagulopathy in Cardiac Surgery: An Update - Corrected Proof

Tatyana Rozental, Linda Shore-Lesserson — 2012-05-18

THERE ARE ABOUT 1.5 million adult cardiac surgical procedures performed in the United States every year, enabled by the use of extracorporeal circulation (ECC). The nature of the procedure and the underlying disease subject the cardiovascular patient population to different hematologic insults. Despite a heightened awareness of the various adverse effects of blood product transfusions, the publication of national transfusion guidelines, and an acceptance of lower transfusion thresholds, allogeneic blood product usage remains as high as 50% in cardiac surgical patients.

Dynamic Mitral Regurgitation Without Regional Wall Motion Abnormality - Corrected Proof

Greg Balfanz, Harendra Arora, Brett C. Sheridan, Jason N. Katz, Priya A. Kumar — 2012-05-18

A55-YEAR-OLD white man was transferred from an outside hospital with complaints of chest tightness and pain radiating to his jaw and left arm. These symptoms were associated with shortness of breath and diaphoresis. A cardiac catheterization revealed triple-vessel coronary artery disease (75% stenosis in the left anterior descending artery, 80% stenosis in the left circumflex artery near the takeoff of the obtuse marginal artery, and 80% stenosis in the right coronary artery). A transthoracic echocardiogram showed normal left ventricular (LV) function and mitral valve leaflets that were mildly thickened with normal mobility and trivial-to-mild mitral regurgitation (MR) ( [supplementary videos are available online]). The patient consented to coronary artery bypass graft (CABG) surgery.

Variability in Transfusion Practice and Effectiveness of Strategies to Improve It - Corrected Proof

Aryeh Shander, Thomas Puzio, Mazyar Javidroozi — 2012-05-18

MORE THAN 150 YEARS have passed since Professor William Guy delivered his Croonian Lectures on the application of the “numerical method,” more commonly known as “statistics,” to the “science and art of medicine” at the Royal College of Physicians. The debate over whether medicine is more a science or an art persists to this day. Although the exact definition of medicine as a science versus an art is open to wide interpretation, the science of medicine can be defined as the “knowledge” accumulated over the years and the art of medicine as the “skill” of the practitioner in applying the knowledge and dexterity in practice. The task of synthesizing up-to-date, evidence-based knowledge and conveying it to the clinicians is in itself daunting. Hoping that clinicians adopt the knowledge and apply it effectively in caring for their patients is another challenge. Indeed, this struggle spans almost every field and aspect of medicine (eg, cardiac surgery, a marvelous and intriguingly complicated procedure requiring great skills; and the transfusion of blood, one of the most common and rapidly increasing procedures among hospitalized patients in the United States).

Transesophageal Echocardiographic Monitoring During Vascular Surgery in a Patient with Unanticipated Critical Aortic Stenosis - Corrected Proof

Nicholas Wasson, Robina Matyal — 2012-05-16

A 73-YEAR-OLD white man, presented for left common femoral-to-deep femoral artery bypass grafting of his left lower extremity for acute pain at rest. His past medical history was significant for coronary artery disease that required the placement of drug-eluting stents in his left anterior descending, left circumflex, and right coronary arteries. He had a history of occasional stable angina with a history of one episode of congestive heart failure and uncontrolled type-II diabetes mellitus complicated by peripheral neuropathy and renal insufficiency and a recent cerebrovascular accident with residual right-side weakness and mild aphasia. He also had a 45–pack year history of smoking, significant chronic obstructive pulmonary disease, and obstructive sleep apnea. His preoperative transthoracic echocardiographic examination showed a 30% to 35% ejection fraction and mild-to-moderate aortic stenosis. There was mild mitral and tricuspid regurgitation.

Comparison of the Effects of Sevoflurane, Isoflurane, and Desflurane on Microcirculation in Coronary Artery Bypass Graft Surgery - Corrected Proof

2012-05-16

Objective: This investigation was performed to compare the effects of inhalation agents on microcirculation in coronary artery bypass grafting (CABG) using orthogonal polarization spectral imaging. Design: This prospective and randomized study was performed in patients scheduled for CABG surgery from March through September 2010. Setting: Tertiary care university hospital. Participants: Thirty patients undergoing elective CABG. Interventions: Patients were assigned to sevoflurane, desflurane, or isoflurane. Measurements and Main Results: Orthogonal polarization spectral imaging was used to evaluate the sublingual microcirculation. Hemodynamic variables (heart rate, mean arterial pressure, central venous pressure, cardiac output, and pulmonary capillary wedge pressure), laboratory parameters (hematocrit, lactate, and potassium), and microcirculatory variables (total vascular density [TVD] [mm/mm2], microvascular flow index [MFI] [arbitrary units], perfused vessel density [PVD] [mm/mm2], and proportion of perfused vessels [PPV] [percentage] were obtained before induction, after induction, during cardiopulmonary bypass, at the end of surgery, and 24 hours after surgery. The greatest alterations in microcirculation parameters were found during cardiopulmonary bypass. In the sevoflurane group, TVD (14.7%), PVD (22%), PPV (5.97%, p < 0.05), and MFI (7.69%, p > 0.05) were decreased. In the isoflurane group, TVD (14.7%) and PVD (20.3%) were decreased, whereas PPV (1.69%) and MFI (17.99%) were increased (p < 0.05). In the desflurane group, there were no changes in TVD and PVD, but MFI (8.99%, p > 0.05) and PPV (1.48%, p < 0.05) were increased in the small vessels. These changes returned to their initial values 24 hours postoperatively. Conclusions: Sevoflurane had a negative effect on the microcirculation. Isoflurane decreased vascular density and increased flow. Desflurane produced stable effects on the microcirculation. These inhalation agents induced transient alterations in microvascular perfusion.

Airway Management and Lung Isolation in a Patient With a Massive Cavernous Hemangioma of the Tongue - Corrected Proof

Donn Marciniak, Erik Kraenzler — 2012-05-16

INTRAMUSCULAR HEMANGIOMAS are common vascular tumors, yet only approximately 14% are found in the head and neck region. Invasive muscular hemangiomas are even more uncommon, making up less than 1% of these tumors, and massive cavernous variations are only described anecdotally. A unique risk to this lesion is uncontrolled hemorrhage, and several fatalities have been described. There is no detailed description of airway management in this patient population, and the present case report highlights important considerations in performing safe endotracheal intubation followed by lung isolation.

A Right Atrial Mass in a Patient With Metastatic Melanoma and Prostate Cancer - Corrected Proof

Bryan G. Maxwell, Matthew Forrester, Michael J. Wagner — 2012-05-16

A 65-YEAR-OLD MAN with coronary artery disease (70% in-stent restenosis of the left anterior descending artery) and aortic valve stenosis (mean gradient 34 mmHg, valve area 0.8 cm2) presented for coronary artery bypass grafting and aortic valve replacement. His medical history was notable for prostate cancer treated with pelvic irradiation and metastatic melanoma of unknown primary site diagnosed on excisional biopsy of a neck mass. After anesthetic induction, a pulmonary artery catheter was inserted without difficulty through the right internal jugular vein. Transesophageal echocardiography (TEE) confirmed the aortic valve stenosis and unexpectedly revealed a mobile, spherical, pedunculated, homogenously echogenic mass in the inferior-posterior aspect of the right atrium. The intracardiac mass was best seen in midesophageal 4-chamber and right ventricular inflow-outflow TEE views (, [ is available online]). This mass had not been seen during preoperative transthoracic echocardiography. Color Doppler echocardiography indicated that the mass did not appear to be highly vascular. Trace-to-mild tricuspid regurgitation also was present. What is the diagnosis?

Transcatheter Aortic Valve Replacement—Part 3: The Central Role of Perioperative Transesophageal Echocardiography - Corrected Proof

Prakash A. Patel, Jens Fassl, Annemarie Thompson, John G.T. Augoustides — 2012-05-14

TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR) has emerged as an attractive management option in high-risk patients with severe aortic stenosis (AS), typically the elderly patient with multiple comorbidities. Since its introduction 10 years ago, significant advances have resulted in widespread dissemination with ongoing improvements in hardware design, procedural success, and clinical outcomes. A pivotal randomized controlled trial (N = 358: 21 participating centers) has shown that TAVR significantly improved survival as compared with optimal medical management in patients with AS deemed too high risk for surgical aortic valve replacement (AVR) (hazard ratio = 0.55; 95% confidence interval, 0.40-0.74; p < 0.001). A companion randomized trial (N = 699: 25 participating centers) that compared TAVR with surgical AVR in high-risk patients showed that TAVR was clinically equivalent to conventional AVR. Consequently, the worldwide TAVR experience should continue to expand because it already represents a viable management option in high-risk patients with AS.

Immobile Transesophageal Echocardiographic Probe After Cardiopulmonary Bypass - Corrected Proof

Frederick T. Conlin, Andrew R. Sifain, Peter A. Knight, David H. Stern — 2012-05-14

TWO-DIMENSIONAL transesophageal echocardiography (TEE) has become a standard method of monitoring patients undergoing cardiac surgery. TEE provides valuable real-time information on myocardial contractility and volumes and permits the assessment of hemodynamic parameters and valvular function. TEE is an extremely safe diagnostic tool, particularly in appropriately screened subjects. However, there are risks associated with probe insertion and manipulation, including, but not limited to, esophageal perforation, damage to the oropharynx, thermal injury, buckling of the transducer, arrhythmias, and airway obstruction.

Difficult and Complex Separation from Cardiopulmonary Bypass in High-Risk Cardiac Surgical Patients: A Multicenter Study - Corrected Proof

2012-05-14

Objectives: To determine the impact of the pharmacologic and mechanical support required during separation from cardiopulmonary bypass (CPB) on survival after cardiac surgery. The authors hypothesized that difficulty with separation from CPB was associated independently with life-threatening complications and survival after cardiac surgery. Design: Prospective study. Setting: Nineteen tertiary care hospitals involved in the Blood Conservation Using Antifibrinolytics in a Randomized Controlled Trial (BART). Participants: High-risk cardiac surgical patients. Intervention: Separation from CPB was stratified as easy when no support or only one vasoactive agent or inotrope was required, difficult or pharmacologically assisted when the 2 drug types were used, and complex when the first weaning process failed or the patient required mechanical devices to be weaned from CPB. These definitions were based on a retrospective analysis of 6,120 consecutive cardiac surgical patients who underwent cardiac surgery in a single center. Measurements and Main Results: Backward logistic regression was performed to determine predictors of life-threatening complications and mortality. There were 2,331 patients with a mean age of 66 ± 11 years, and 71.8% were men. There were 1,158 (49.7%), 835 (35.8%) and 338 (14.5%) patients in the easy, difficult, and complex categories, respectively. One hundred eight patients died (4.6%), 84 (77.8%) of whom had difficulty in weaning from CPB. Complex separation from CPB was found to be an independent predictor of mortality (odds ratio 3.091, 95% confidence interval 1.706-5.601). Conclusions: Difficulty in the process of separation from CPB is an independent predictor of mortality and adverse outcome after cardiac surgery (Current Controlled Trials, indentifier ISRCTN15166455).

Systemic Magnesium to Reduce Postoperative Arrhythmias After Coronary Artery Bypass Graft Surgery: A Meta-Analysis of Randomized Controlled Trials - Corrected Proof

Gildasio S. De Oliveira, Jennifer S. Knautz, Saadia Sherwani, Robert J. McCarthy — 2012-05-07

Objective: To evaluate the effect of systemic magnesium on the prevention of postoperative cardiac arrhythmias after coronary artery bypass graft surgery. Design: A meta-analysis. Setting: Randomized controlled trials evaluating the effect of systemic magnesium on the incidence of postoperative arrhythmias. Participants: Patients undergoing coronary artery bypass graft surgery. Interventions: Systemic perioperative administration of magnesium sulfate. Measurements and Main Results: Twenty studies evaluating 3,696 subjects were included. The combined effect suggested that systemic magnesium reduced the incidence of supraventricular arrhythmias compared with saline (odds ratio [OR] = 0.69; 95% confidence interval [CI], 0.53-0.90; number needed to treat [NNT] = 14). The effect was present for lower-quality studies (Jadad score ≤3; OR = 0.47; 95% CI, 0.28-0.81; NNT = 8), but it was not detected for higher-quality studies (Jadad >3; OR = 0.85; 95% CI, 0.66-1.11). There was no association between the total dose of magnesium administration and the incidence of supraventricular arrhythmias (p = 0.19). There was no effect of magnesium on the incidence of postoperative stroke, myocardial infarction, and death. In addition, magnesium did not reduce the hospital or intensive care unit lengths of stay (all p > 0.05). Conclusions: The effect of magnesium sulfate in reducing postoperative supraventricular arrhythmias was significant when examined by lower-quality studies but not when examined by higher-quality studies. This fact probably is responsible for controversial findings reported in the literature. Also, magnesium sulfate did not reduce the incidence of complications associated with the development of postoperative cardiac arrhythmias. More effective strategies should be used to prevent complications caused by arrhythmias in this patient population.

A Left Atrial Mass in a Middle-Aged Woman: Just Another Myxoma? - Corrected Proof

2012-05-07

A 51-YEAR-OLD WOMAN presented with a 6-month history of dizziness and palpitations both at rest and with activity. These symptoms worsened in the supine position, which necessitated sleeping on an incline. She also complained of progressively worsening dyspnea on exertion. She reported a diminished appetite over the last few months but no significant weight loss. She also experienced intermittent episodes of nausea and vomiting. Transesophageal echocardiography was performed as part of the diagnostic evaluation ( and Videos 1-3 []). What is the diagnosis?

Reflections on an Electrocardiogram: Inverted T Waves - Corrected Proof

David S. Palilla, Theodore A. Alston — 2012-05-07

A 60-YEAR-OLD WOMAN with diabetes mellitus, myocardial infarction, and coronary artery stents suffered a pulmonary embolism because of deep venous thrombosis. Rectus sheath hematomas complicated anticoagulation, and an infrarenal vena cava filter was placed. She was sent to the authors' center a month later when venous thrombosis caused acute massive swelling of both legs. She was brought to the operating room for percutaneous vortex thrombectomy with femoral–right atrial venovenous bypass. New T-wave inversion was seen on an electrocardiogram (ECG) taken upon arrival to the operating room. Lead placement was unchanged. What was the cause of this new T-wave inversion? How was this abnormality corrected acutely ()?

Pediatric Airway Scope Is Available for Gastric Tube Insertion in Adult Patients - Corrected Proof

Hirotoshi Kitagawa, Yasuhiko Imashuku, Toji Yamazaki — 2012-05-07

In our anesthetic management of coronary artery surgery, gastric tube (GT) insertion is a routine practice after intubation. Occasionally, a small mucosal injury caused by the blind insertion of a GT (including postcricoid ulceration and vocal cord paralysis) may induce massive hemorrhage because of the systemic administration of heparin during cardiac surgery. To avoid this complication, the GT insertion preferably should be performed under visual control during the GT advancement. Until recently, most visualization devices, including the Airway Scope (AWS; Pentax-AWS, Hoya, Tokyo, Japan), limited the oropharyngeal manipulations because narrowing of the oropharyngeal space by the endotracheal tube interferes with the advancement of the laryngoscope and decreases visibility of the posterior larynx. Recently, a new AWS blade for children, which is smaller than that for adults, has been made available for pediatric endotracheal intubation. This blade also can pass through a narrow upper airway and visualize the hypopharynx in adult anesthetized, endotracheally intubated patients. We report the use of this new pediatric blade for the insertion of the GT in an endotracheally intubated adult patient.

A Large Mass in the Right Anterior Chest - Corrected Proof

2012-05-07

A70-YEAR-OLD MAN with a history of coronary artery disease, severe aortic stenosis, obesity, type-2 diabetes mellitus, hypertension, and chronic obstructive pulmonary disease was admitted for coronary artery bypass grafting and aortic valve replacement. The physical examination showed a morbidly obese individual with a barrel chest; he was in no acute distress. He had diffuse faint wheezes and decreased breath sounds bilaterally (right greater than left). A pulmonary function test showed a forced expired volume in 1 second of 30% of predicted. Chest radiographs were obtained as part of the preoperative evaluation and displayed a large density in the right anterior chest (). A thoracic computed tomographic scan confirmed the presence of a large mass in the anterior mediastinum and right chest (). What is the diagnosis?

CARDIAC CALENDAR—2012 to 2013 - Corrected Proof

George Silvay — 2012-05-07

International Forum of Cardiovascular Anesthesia, Chinese Heart Congress. Beijing, China. August 11-13, 2012. Information: http://www.CHCIFCA2012.com. 4th Annual Joint Conference of Scandinavian Association of Cardiothoracic Surgery. Vilnius, Lithuania. August 16-18, 2012. Information: http://www.sats2012.com/invitation.

Perioperative Management of Antiplatelet Agents in Patients Undergoing Cardiac Surgery - Corrected Proof

Shahar Lavi, Ronit Lavi — 2012-04-25

SURGICAL REVASCULARIZATION for coronary artery disease is one of the most common surgeries performed. With constant aging of the world's population and the increase in the number and complexity of percutaneous coronary interventions (PCIs), there is a shift toward performing coronary artery bypass graft (CABG) surgery among an elderly and sicker patient population. To reduce the risk of cardiovascular events in these higher-risk patients, there is a need for more intensive medical therapy, including the use of antiplatelet agents. The caveat is that these patients are also at an increased risk for adverse events and complications related to medical therapy.

Transcutaneous Ultrasound Measurements of Carotid Flow to Monitor for Cerebral Malperfusion During Type-A Aortic Dissection Repair - Corrected Proof

Juan N. Pulido, Brian S. Pallohusky, Soon J. Park, David J. Cook — 2012-04-25

THE REPAIR OF TYPE-A aortic dissection often requires alternative sites for arterial cannulation for cardiopulmonary bypass (CPB). The risks of cannulation of the femoral artery for the institution of CPB are well known and include retrograde perfusion of the false lumen with potential worsening of the dissection with compromise of organ perfusion, and retrograde embolization. Some techniques, including axillary artery, transapical aortic, and central aorta cannulation, have been described to minimize this complication. Some of these techniques require more time and may not be appropriate for all patients.

An Evaluation of Factors Affecting Activated Coagulation Time - Corrected Proof

2012-04-25

Objective: Although failure to achieve an adequate activated coagulation time (ACT) after full heparinization before cardiopulmonary bypass often is attributed to antithrombin (AT) deficiency, it remains unclear if this is a causative mechanism of decreased heparin responsiveness. Therefore, the authors determined the relationship between AT and other coagulation-related factors that affect the ACT measurement and heparin sensitivity index before the establishment of cardiopulmonary bypass. Design: Observational study. Setting: University medical center. Participants: Adult elective cardiac surgical patients. Interventions: Preoperative data collection included demographics, type of preoperative medical therapy, hemoglobin, platelet count, and AT. Intraoperative measurements included ACT and anti-Xa activity. Results: Of the 203 patients enrolled in this study, 10% (n = 21) did not achieve an adequate ACT (≥400 seconds) after full heparinization. Subnormal AT activity (55%-79%) was not related to a low ACT and a low heparin sensitivity index. Preoperative low-molecular-weight heparin therapy did not cause a decreased ACT response. However, preoperative low hemoglobin levels and high platelet counts were associated with a decreased ACT. Conclusions: All these observations suggest that failure to achieve an adequate ACT is, in general, not an indicator of AT deficiency but could be affected by high platelet counts and low hemoglobin levels.

Acute Kidney Injury After Cardiac Surgery: Does the Time Interval From Contrast Administration to Surgery Matter? - Corrected Proof

David R. McIlroy, M. Clin Epi, Michael Argenziano, David Farkas, Tianna Umann — 2012-04-23

Objective: The authors sought to evaluate the association between the time interval from contrast administration to cardiac surgery and postoperative acute kidney injury (AKI). Design: A retrospective observational study over a 1-year period. Setting: A US academic medical institution. Participants: Six hundred forty-four adult patients undergoing nonemergent cardiac surgery. Interventions: No interventions were performed as part of the study. Measurements and Main Results: AKI was defined as an increase in serum creatinine by ≥0.3 mg/dL or ≥50% above baseline within the first 2 postoperative days or the commencement of renal replacement therapy within the same period. Using a contrast-to-surgery time interval >7 days as the baseline, multivariable logistic regression analysis determined the association between a contrast-to-surgery time interval ≤1 day or 2 to 7 days and postoperative AKI adjusting for potential confounding variables. The incidence of AKI within the study cohort was 21.9%. After adjusting for other covariates, there was no association between the contrast-to-surgery time and AKI (odds ratio [OR] ≤1 day = 0.93; 95% confidence interval [CI], 0.52-1.66; p = 0.81; OR = 2-7 days = 1.28; 95% CI, 0.78-2.11; p = 0.34). Conclusions: In an appropriately selected population, cardiac surgery can be performed within 1 day of cardiovascular catheterization and contrast administration without an increase in the incidence of postoperative AKI. Recommendations to delay cardiac surgery for a specified period after contrast administration to reduce the risk of postoperative AKI are premature. Additional evidence is required before making recommendations on optimal surgical timing after contrast exposure.

Unusual Mobile Structure in the Left Ventricular Outflow Tract Leading to Re-exploration After Elective Aortic Valve Replacement - Corrected Proof

Michael Gilbert, Adrian Ionescu — 2012-04-23

A75-YEAR-OLD WOMAN underwent an aortic valve replacement (AVR) for degenerative aortic stenosis (AS) and coronary artery bypass graft surgery (CABG) for severe 3-vessel coronary artery disease. Before cardiopulmonary bypass (CPB), a transesophageal echocardiographic (TEE) study showed moderate AS with restricted opening of the right and noncoronary cusps but minimal calcification of the valve cusps or annular tissue. No intracardiac masses were visible. Bioprosthetic AVR and triple CABG surgery were performed uneventfully.

CASE xx—2012Suspected Amiodarone Hepatotoxicity After Cardiac Surgery - Corrected Proof

2012-04-20

A57-YEAR-OLD man with a history of chronic chest pain, coronary artery disease with prior non-ST elevation myocardial infarction, and stage IV chronic renal insufficiency (baseline creatinine = 4.4, not requiring dialysis) presented for elective coronary artery bypass surgery. His anesthesia was complicated by aspiration on induction (treated with bronchoscopy and administration of steroids). Before his operation, he had no known drug allergies. He underwent 4-vessel coronary artery bypass graft surgery (left internal mammary artery to left anterior descending artery, saphenous vein graft [SVG] to obtuse marginal [OM] 1, SVG to OM2, and SVG to first diagonal) with cardiopulmonary bypass, which was uncomplicated. Intraoperatively, he received 500 mL of crystalloids, 500 mL of colloids, no blood products, and produced 225 mL of urine. He arrived at the intensive care unit requiring atrial-ventricular pacing for complete heart block with a junctional escape rhythm.

Preventable Risk Factors for Acute Kidney Injury in Patients Undergoing Cardiac Surgery - Corrected Proof

Pradeep Arora, Hari Kolli, Neha Nainani, Nader Nader, James Lohr — 2012-04-20

ACUTE KIDNEY INJURY (AKI) develops in 5% to 42% of patients who undergo cardiac surgery depending on the definition of AKI, and 1% to 4% of patients require dialysis. AKI requiring dialysis after cardiac surgery is associated with an increased incidence of infection, length of critical care unit stay, and long-term need for dialysis. Chertow et al have shown that AKI requiring dialysis is an independent risk factor for mortality after cardiac surgery. Recent studies have shown that even small increases in serum creatinine (≥0.3 mg/dL) postoperatively are associated with increased mortality.

Atrial Fibrillation Complicating Left Pneumothorax After Malpositioning of a Double-Lumen Tube - Corrected Proof

Sahar M. Siddik-Sayyid, Jean J. Esso, Marie T. Aouad — 2012-04-20

A 66-year-old woman (weight 133.3 lbs, height 158 cm) was scheduled for atrial septal defect (ASD) repair through a thoracotomy. Preoperative chest radiography was normal, and an electrocardiogram showed an incomplete right bundle-branch block. Transesophageal echocardiography revealed moderate right atrium and ventricle dilation, a pulmonary arterial pressure of 52 mmHg, and an ASD-associated left-to-right shunt. In the operating room, her blood pressure was 125/75 mmHg, her heart rate was 94 beats/min, and the SpO2 was 97% on room air. The patient was intubated with a 35F left-sided double-lumen tube (DLT) under direct laryngoscopy to a depth of 31 cm at the incisors. The DLT placement was checked by auscultation. During manual ventilation, increased airway resistance was noted, and no breath sounds were heard over either lung fields. The tube was pulled back 2 cm, and bilateral breath sounds were again documented. The end-tidal carbon dioxide waveform was present on the monitor. At that time, rapid-rate atrial fibrillation of 130 beats/min occurred with a blood pressure of 63/40 mmHg. Phenylephrine boluses were given to maintain hemodynamic stability. Correct positioning of the DLT was confirmed by fiberoptic bronchoscopy. Meanwhile, SpO2 remained within the normal range. Soon thereafter, a median sternotomy was performed instead of a thoracotomy, and a left pneumothorax was diagnosed and released by pleural opening. This was followed by rapid conversion of the atrial fibrillation into sinus rhythm and restoration of normal blood pressure.

Retromolar Placement of a Double-Lumen Tube: Novel Approach for a Difficult Airway - Corrected Proof

2012-04-20

The placement of a double-lumen tube (DLT) is widely considered the technique of choice for lung isolation and one-lung ventilation. Unfortunately, the insertion and positioning of a bulky and rigid DLT may not always be straightforward, especially in patients with difficult airways. We present the case of a patient requiring right-lung isolation in whom placement of a DLT between the teeth was deemed to be very difficult. To overcome this challenge, as an alternative to the use of a single-lumen tube (SLT) with a bronchial blocker, we describe a novel approach using the retromolar space (RMS) as a point of entry for DLT placement.

An Unusual Radio-opaque Shadow in the Chest Radiograph After Coronary Artery Bypass Surgery - Corrected Proof

2012-04-20

A 50-YEAR-OLD, 175-cm, 140-lb man requiring a triple-vessel coronary artery bypass was admitted to the authors' hospital. The preoperative chest radiograph was normal. Per institutional protocol, a femoral arterial catheter and a pulmonary artery catheter (PAC) were inserted under local anesthesia. During the insertion of the PAC, it was noted that the catheter had to be advanced beyond 50 cm to achieve a wedge position. During surgery, the left anterior descending coronary artery and the first and second obtuse marginal coronary arteries were grafted by the off-pump method. At the end of the surgical procedure, the count of equipment, needles, and gauze pieces were correct. The patient was transferred to the intensive care unit for postoperative management. A routine postoperative chest radiograph revealed a crescent-shaped “foreign body” superimposed on the cardiac shadow in the region of the main pulmonary artery (). Initially, it was suspected that one of the intracoronary shunts used was left behind inadvertently in the chest, but the instrument count was correct. The decision whether to re-explore to retrieve the “foreign body” had to be made. What is the diagnosis?

Exogenous Surfactant Therapy in Acute Lung Injury/Acute Respiratory Distress Syndrome: The Need for a Revised Paradigm Approach - Corrected Proof

Ahilanandan Dushianthan, Rebecca Cusack, Mike Grocott, Anthony Postle — 2012-04-20

We were interested to read the meta-analysis on exogenous surfactant therapy in adult patients with acute respiratory distress syndrome (ARDS)/acute lung injury (ALI) conducted by Meng et al. Although the results were disappointing, the findings were not surprising, and they were in line with 2 previously published meta-analyses. The surfactant clinical trials included here are highly informative, albeit producing negative clinical outcomes, and suggest the necessity for a revised paradigm approach for future surfactant clinical trials.

Subcutaneous Emphysema Causing Inefficient Ultrasound Guidance During Central Vein Cannulation - Corrected Proof

Gokhan Inangil, Kadir Hakan Cansiz, Ahmet Erturk Yedekci, Huseyin Sen — 2012-04-20

We have read with great interest the articles about the landmark technique and ultrasound guidance (USG) for safety and verification procedures in successful central venous cannulation (CVC). We would like to present a similar experience regarding a patient with inefficient USG during internal jugular vein cannulation.

Con: Transcatheter Aortic Valve Implantation Should Not Be Performed Under General Anesthesia - Corrected Proof

Fabio Guarracino, Giovanni Landoni — 2012-04-16

ACCORDING TO international guidelines, the proper treatment for symptomatic patients affected by severe aortic stenosis (AS) involves aortic valve (AV) replacement. Many symptomatic elderly patients with significant comorbidities are considered at high risk for surgical AV replacement. These fragile patients cannot tolerate the surgical stress associated with sternotomy, cardiopulmonary bypass, aortic cross-clamping, hypothermia, systemic inflammatory response, blood product transfusion, general anesthesia (GA), and mechanical ventilation ().

Venovenous Extracorporeal Membrane Oxygenation in Adults: Practical Aspects of Circuits, Cannulae, and Procedures - Corrected Proof

2012-04-16

INTEREST IN extracorporeal membrane oxygenation (ECMO) for treating severe respiratory failure in adults has increased substantially in the last 5 years. There are several reasons for this increase. The first reason is the publication of the CESAR study in 2009, which showed improved survival in adults with severe acute respiratory distress syndrome (ARDS) randomized to consideration of ECMO compared with patients treated conventionally. Second is the H1N1 influenza pandemic of 2009 and 2010, which resulted in a substantial increase in the use of ECMO for treating severe respiratory failure. The outcome from ECMO in this group of patients was excellent, with reported survival rates of 68% to 77%. The third factor has been improvements in the equipment used for ECMO; in particular, the introduction of polymethylpentene (PMP) oxygenators, second-generation centrifugal pumps, and cannulae specifically designed for ECMO. Finally, ECMO increasingly is being used for patients undergoing surgical correction of critical airway obstruction (eg, tracheal papilloma).

Pro: Transcatheter Aortic Valve Implantation Should Be Performed With General Anesthesia - Corrected Proof

Jens Fassl — 2012-04-16

TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI) should be performed under general anesthesia (GA). Presently, GA has been shown to be the most commonly used anesthesia technique. In Europe at present, aortic valve access via the transapical, transfemoral, and transaxillary approaches is used in conjunction with the 2 clinically used aortic valve prostheses.

A Large Hiatal Hernia Exacerbated After Aortic Surgery: An Unusual Cause of Heart Failure - Corrected Proof

Miki Matsuda, Ryu Okutani, Mami Ueda, Kei Kamiutsuri, Kazuo Nakada, Yutaka Oda — 2012-04-16

We report a case of a giant hiatal hernia exacerbated after aortic surgery, compressing the left atrium and resulting in heart failure. A 76-year-old woman presented for emergency replacement of the aorta for acute type A aortic dissection. She had a history of asymptomatic hiatal hernia. On admission, she was conscious with no complaint of dyspnea. Her vital signs were stable, and her peripheral oxygen saturation (SpO2) was 98% under oxygen inhalation of 5 L/min. A chest x-ray showed the dilated ascending aorta and a large abnormal shadow overlapping the cardiac silhouette (). A computed tomography (CT) scan revealed a large hiatal hernia with intrathoracic extension as well as a dissected aorta. The stomach was located behind the left atrium with resultant anterior shift of the whole heart.

Innovative Technologies Applied to Anesthesia: How Will They Impact the Way We Practice? - Corrected Proof

Maxime Cannesson, Joseph Rinehart — 2012-04-16

“The future is already here. It is just unevenly distributed.” William Gibson, The Economist, December 4, 2003 PREDICTING THE FUTURE is usually the domain of card readers and psychics. However, given the ongoing exponential growth of medical technology, informatics, systems automation, and computer processing power that is being witnessed, it is becoming evident that a deep understanding of how new technologies will impact medical practice (not just clinical care but also research, education, and management) is of major importance for clinicians who will be in practice for the next 20 to 30 years and want to remain at the forefront of their chosen specialty. Understanding technology will be as important in anesthesia as understanding anatomy, physiology, and pharmacology.

Arterial Desaturation and Left Atrial Contrast Opacification After Tetralogy of Fallot Repair - Corrected Proof

2012-04-16

A4-YEAR-OLD GIRL (height 102 cm, weight 11 kg) with central cyanosis was transported to the operating room for a total intracardiac repair under cardiopulmonary bypass (CPB). The preoperative transthoracic echocardiography diagnosis was that of a tetralogy of Fallot with a complete atrioventricular septal defect (), left atrial isomerism, interrupted inferior vena cava continuing as the azygos vein draining into the right superior vena cava, and a persistent left superior vena cava draining into a dilated coronary sinus.

A Right Atrial Mass in a Patient Undergoing Redo Coronary Artery Bypass Graft Surgery - Corrected Proof

Raghavendra Govinda, Stefan Ianchulev — 2012-04-16

A 73-YEAR-OLD MAN presented to the authors' hospital with chest pain at rest and a 2-month history of increasing shortness of breath. Twelve years earlier, he had undergone coronary artery bypass graft surgery with a left internal mammary artery graft to the left anterior descending artery and a saphenous vein “Y” graft to the posterior descending artery (PDA) and the posterior-lateral ventricular (PLV) branch of the right coronary artery (RCA). A chest radiograph showed moderate cardiomegaly and the absence of mediastinal widening. Preoperative transthoracic echocardiography revealed severe hypokinesia of the basal inferior wall and the basal inferior septum and a 3.3 × 4.8 cm, sessile, nonobstructive, immobile mass protruding into the right atrium and right ventricle. The mass did not appear to impede blood flow across the tricuspid valve ( and [supplementary videos are available online]). What is the diagnosis?

Coronary Artery Bypass Graft Surgery in a Patient With Concomitant Factor V Leiden Mutation and Thromboangiitis Obliterans - Corrected Proof

Gokhan Inangil, Ahmet Erturk Yedekci, Huseyin Sen — 2012-04-16

We have read several articles in JCVA reviewing doctors' experiences with pulmonary embolism and thromboembolic prophylaxis. We would like to report a similar experience of ours regarding a patient undergoing coronary artery bypass surgery and with a medical history of recurrent deep venous thrombosis and pulmonary thromboembolism.

Analgesic Benefits of Preincisional Transversus Abdominis Plane Block for Abdominal Aortic Aneurysm Repair - Corrected Proof

Faraj W. Abdallah, Al Moataz Billah F. Adham, Vincent W. Chan, Ghassan E. Kanazi — 2012-04-13

ABDOMINAL AORTIC ANEURYSM (AAA) surgery is associated with morbidity and mortality. Postoperative epidural analgesia is superior to intravenous patient-controlled analgesia (PCA) in post-AAA surgery pain control; reduction of postoperative myocardial infarction risk; and lowering the risk of cardiovascular, pulmonary, renal, and gastrointestinal complications. Additionally, epidural analgesia reduces the duration of postoperative mechanical ventilation.

Spectral Entropy Monitoring Reduces Anesthetic Dosage for Patients Undergoing Off-Pump Coronary Artery Bypass Graft Surgery - Corrected Proof

2012-04-13

Objectives: The measurement of the depth of anesthesia is of clinical interest for patients undergoing off-pump coronary artery bypass graft (OPCAB) surgery in order to avoid intraoperative awareness and cardiac depression. Entropy recently was introduced as a monitor of anesthetic depth. This study was conducted to investigate the feasibility of entropy monitoring during the conduct of OPCAB surgery and to find out whether it reduced the anesthetic dosage for patients undergoing OPCAB surgery. Design: A prospective, randomized, single-blind, controlled study. Setting: A teaching hospital. Participants: Seventy patients scheduled for OPCAB surgery were randomized to receive propofol-sufentanil anesthesia either with the entropy values visible (the entropy group, n = 35) or without the entropy values visible (the control group, n = 35). Interventions: In the entropy group, propofol and sufentanil infusion rates were titrated to maintain a state entropy (SE) value of 45 to 55 and a response entropy (RE)-SE difference below 10 U. In the control group, patients were anesthetized to keep the heart rate and blood pressure within 25% of the baseline values. Measurements and Main Results: The course of surgery, the consumption of anesthetics, and intraoperative recall were recorded. Plasma levels of adrenocorticotropic hormone (ACTH) and cortisol were measured. The average SE during anesthesia was 50 ± 5 in the entropy group; the entropy values were lower in the control group (p < 0.05). Compared with the control group, propofol and sufentanil consumption were significantly less in the entropy group, which shortened the time to tracheal extubation (p < 0.05). Significantly, patients in the control group needed more phenylephrine to maintain arterial pressure than patients in the entropy group (p < 0.05). ACTH and cortisol release were prevented completely, and there was no intraoperative recall reported in the 2 groups. Conclusions: Entropy monitoring reduced propofol and sufentanil dosage for patients undergoing OPCAB surgery.

Carotid Endarterectomy Plus Medical Therapy or Medical Therapy Alone for Carotid Artery Stenosis in Symptomatic or Asymptomatic Patients: A Meta-Analysis - Corrected Proof

Joanne Guay, E. Andrew Ochroch — 2012-04-12

Objective: The purpose of this study was to compare carotid endarterectomy (CEA) plus medical therapy (MT) with MT alone for symptomatic and asymptomatic patients suffering from carotid artery stenosis in terms of long-term stroke/death rate. Design: A meta-analysis of parallel randomized, controlled trials (RCTs) (blind or open) published in English. Setting: A university-based electronic search. Participants: Patients suffering from carotid artery stenosis symptomatic or not. Interventions: Patients were subjected to CEA plus MT or MT alone. Measurements and Main Results: For asymptomatic patients, 6 RCTs comprising 5,733 patients (CEA = 2,853 and MT = 2,880) were included. CEA did not affect the stroke/death risk for asymptomatic patients (risk ratio [RR] = 0.93; 95% confidence interval [CI], 0.84 to 1.02; I2 = 0%; p = 0.14). For symptomatic patients, 2 RCTs were included. They had 5,627 patients (CEA = 3,069 and MT = 2,558) of whom 2,295 patients (CEA = 1,213; MT = 1,082) had severe stenosis (North American Symptomatic Carotid Endarterectomy Trial [NASCET] technique ≥50% and European Carotid Surgery Trial technique ≥70%). CEA decreased the stroke/death risk only for patients with severe stenosis (RR = 0.69; 95% CI, 0.59-0.81; p < 0.001 [random effects model]; I2 = 0% on the odds ratio and 17% on the RR [benefit or harm side]; number needed to treat = 11 [95% CI, 8-17]). Conclusions: CEA is helpful for recently symptomatic patients with carotid artery stenosis ≥50% (NASCET technique) but adds no benefit in terms of stroke/death for asymptomatic patients.

Efforts to Change Transfusion Practice and Reduce Transfusion Rates Are Effective in Coronary Artery Bypass Surgery - Corrected Proof

2012-04-12

Objectives: Efforts to decrease allogeneic blood transfusion and avoid unnecessary transfusions in cardiac surgery are important because transfusions are associated with increased postoperative morbidity and mortality. The purpose of the present study was to evaluate the long-term effects of multidisciplinary efforts to reduce allogeneic blood transfusion rates and avoid unnecessary red blood cell (RBC) transfusions in primary elective coronary artery bypass graft (CABG) surgery. Design: A retrospective observational study. Setting: A single center study in a university-affiliated hospital. Participants: A total of 450 patients undergoing primary elective CABG surgery during 2004, 2008, or 2010. Interventions: The application of systematic multimodal perioperative blood-sparing techniques and interventions directed to change transfusion behaviors. Measurements and Main Results: The results from an audit on transfusion practices in 2004 were compared with similar audits performed in 2008 and 2010 using a before-and-after study design. The patient populations were comparable throughout the years. The median postoperative chest tube bleeding was decreased from 950 mL in 2004 to 750 mL in 2010. The proportion of patients transfused with allogeneic blood products was decreased from 64% to 47%. Overtransfusion with allogeneic RBCs defined as the proportion of patients transfused with RBCs discharged with hemoglobin >7 mmol/L (11.3 g/dL) was reduced from 36% to 16%. Conclusions: Multimodal efforts to change transfusion behaviors and decrease transfusion rates in CABG surgery have persistent effects for several years.

Individual Surgeon's Impact on the Risk of Re-exploration for Excessive Bleeding After Coronary Artery Bypass Surgery - Corrected Proof

2012-04-12

Objective: Excessive bleeding requiring re-exploration is a severe complication that may affect the outcome after coronary artery bypass grafting. The authors hypothesized that surgeon performance may contribute significantly to such a complication. Design: Retrospective. Setting: Tertiary referral center in a university hospital. Participants: Two thousand one patients. Interventions: Isolated coronary artery bypass grafting. Results: Re-exploration for bleeding was performed in 113 patients (5.3%). Re-exploration was performed ≥3 days after surgery in 11 patients. The surgical site of bleeding was identified in 83 patients (73.5%). Rates of re-exploration for excessive bleeding ranged from 1.4% to 11.7% according to different surgeons (p < 0.0001). When adjusted for the additive European System for Cardiac Operative Risk Evaluation, re-exploration for bleeding was associated with increased risks of low-cardiac-output syndrome (odds ratio [OR] 2.239, 95% confidence interval [CI] 1.328-3.777), prolonged need for inotropes (OR 1.894, 95% CI 1.198-2.994), and an intensive care unit stay ≥5 days (OR 2.129, 95% CI 1.202-3.770). Logistic regression showed that an individual surgeon (p < 0.0001), preoperative body mass index <25 kg/m2 (OR 2.733, 95% CI 2.145-3.481), and estimated glomerular filtration rate <30 mL/min/1.73 m2 (OR 3.891, 95% CI 1.669-9.076) were independent predictors of re-exploration for excessive bleeding. An individual surgeon also was an independent predictor of a postoperative blood loss ≥1,600 mL. Conclusions: An individual surgeon has a major impact on postoperative bleeding, and a meticulous surgical technique is expected to decrease significantly such a severe complication.

A Prospective, Randomized, Double-Blinded Comparison Between Multimodal Thoracic Paravertebral Bupivacaine and Levobupivacaine Analgesia in Patients Undergoing Lung Surgery - Corrected Proof

2012-04-06

Objectives: To compare the effects of paravertebral analgesia with levobupivacaine or bupivacaine on intra- and postoperative pain for thoracic surgery. Design: A prospective, randomized, and double-blinded study. Setting: A university hospital. Participants: Forty patients undergoing thoracic surgery. Interventions: Patients received paravertebral catheterization and a bolus (14-20 mL) of 0.5% bupivacaine (n = 20) or 0.5% levobupivacaine (n = 20) with morphine, 60 μg/kg, before the induction of general anesthesia that consisted of a propofol infusion. A paravertebral continuous infusion (0.05 mL/kg/h) of 0.25% bupivacaine or 0.25% levobupivacaine, 100 mL, with added morphine, 10 mg, and clonidine, 0.15 mg, was started at the end of surgery for 72 hours postoperatively. Postoperative rescue diclofenac analgesia was available if required. Measurements and Main Results: The primary outcome was intraoperative fentanyl consumption. Static and dynamic pain scores measured by a visual analog scale were assessed regularly. Intraoperative fentanyl consumption was significantly lower in the levobupivacaine group compared with the bupivacaine group (p = 0.001). On all 3 postoperative days, static pain scores were significantly lower in the levobupivacaine group compared with the bupivacaine group (p < 0.05). Dynamic pain scores were significantly lower in the levobupivacaine group compared with the bupivacaine group during the 2 postoperative days (p < 0.05). A smaller proportion of patients in the levobupivacaine group used rescue analgesia (p < 0.005). Conclusions: Paravertebral analgesia with levobupivacaine resulted in less intraoperative fentanyl consumption, lower static (3 days) and dynamic (2 days) pain scores, and less rescue analgesia than analgesia with bupivacaine.

Dizziness Leads to an Unexpected Diagnosis - Corrected Proof

Paul S. Pagel, Kyle R. Johnson, Alfred C. Nicolosi — 2012-04-05

A61-YEAR-OLD, 105-kg, 170-cm man presented to the authors' institution with a chief complaint of dizziness. The patient acknowledged a medical history of hypertension and hyperlipidemia, but he denied a history of cardiac disease and otherwise was essentially asymptomatic. The physical examination disclosed lower extremity pitting edema but otherwise was unremarkable. Transesophageal echocardiography (TEE) was performed as part of the diagnostic evaluation and displayed the images shown in and (supplementary videos are available online). What is the diagnosis?

Reply to Drs Petricevic et al - Corrected Proof

Reija Mikkola, Fausto Biancari — 2012-04-05

We appreciate Petricevic et al's comments on our article titled “Timing of Preoperative Aspirin Discontinuation and Outcome After Elective Coronary Artery Bypass Graft Surgery,” and we would like to address their concerns. Residual platelet reactivity, so-called aspirin resistance, is certainly a topic of major clinical interest because it may have a significant impact either on thrombotic or bleeding complications before and after coronary artery bypass surgery. However, our study was performed retrospectively, and the point-of-care platelet function analyzers were not available during our study period, so we could not include data on aspirin resistance in the analysis.

Timing of Preoperative Aspirin Discontinuation and Outcome After Elective Coronary Artery Bypass Graft Surgery: A Role of Platelet Function Assessment - Corrected Proof

Mate Petricevic, Bojan Biocina, Sanja Konosic, Visnja Ivancan — 2012-04-05

We read with great interest the recently published retrospective study by Mikkola et al. The authors retrospectively analyzed a consecutive series of 859 patients who underwent elective coronary artery bypass graft (CABG) surgery. With respect to preoperative low-dose aspirin administration, patients were divided into 2 groups: (1) late or no aspirin discontinuation and (2) early discontinuation determined as aspirin withdrawal in more than 3 days before surgical procedure. In our opinion, the lack of objective quantification of the antiplatelet effect of aspirin constitutes a major drawback of the study. The incidence of aspirin nonresponse varies widely in the literature. Nevertheless, because aspirin resistance independently raises the incidence of adverse cardiovascular events, it would seem critical to adjust for this variable. Expected inhibition of platelet function is not always achieved after aspirin administration. Reports in the literature already described a wide variability in platelet response to aspirin therapy with the prevalence of aspirin resistance, as defined by platelet function tests, ranging from 1% to 45%. Residual platelet reactivity, so-called “aspirin resistance,” after aspirin administration might be related to thrombotic complications and major ischemic cardiac events, both pre- and postoperatively. By contrast, there is evidence that certain patients have an accentuated response to the usual doses of preoperative aspirin that may result in increased perioperative blood loss.

Effect of Long-Term Thoracic Epidural Analgesia on Refractory Angina Pectoris: A 10-Year Experience - Corrected Proof

2012-04-05

Objectives: In patients with refractory angina, the adjuvant effects of long-term home self-treatment with thoracic epidural analgesia on angina, quality of life, and safety were evaluated. Design: A prospective, consecutive study. Setting: A university hospital. Participants and Intervention: Between January 1998 and August 2007, 152 consecutive patients with refractory angina began treatment with thoracic epidural analgesia by intermittent injections of bupivacaine (139 home treatment and 13 palliative). Data were collected until August 2008; therefore, the follow-up for each patient was between 1 and 9 years. Measurements and Main Results: All but 7 of the patients improved symptomatically, and the improvement was maintained throughout the period of treatment (median = 19 months; range, 1 month-8.9 years). After 1 to 2 weeks, the median (interquartile range [IQR]) Canadian Cardiovascular Society angina class decreased from 4.0 (3.0-4.0) to 2.0 (1.0-2.0), the mean ± standard deviation frequency of anginal attacks decreased from 36 ± 19 to 4.4 ± 6.8 a week, the nitroglycerin intake decreased from 27.7 ± 15.7 to 2.7 ± 4.9 a week, and the median (IQR) overall self-rated quality of life assessed by the visual analog scale increased from 25 (20-30) to 70 (50-75) (all p < 0.001). About one-third of the patients had a dislodgement of the epidural catheter. Apart from 1 epidural hematoma that appeared in 1 patient with a previously undiagnosed bleeding defect, no other serious catheter-related complications occurred. Conclusions: Long-term self-administered home treatment with thoracic epidural analgesia is a safe, widely available adjuvant treatment for patients with severe refractory angina. It produces symptomatic relief of angina and improves quality of life. The technical development of the method to protect the catheter against dislodgement is needed.

Response: Impaired Lung Function After Intubation and Mechanical Ventilation for Surgical Ligation of the Ductus Arteriosus in Preterm Infants - Corrected Proof

Thierry Dzukou, Thameur Rakza, Laurent Storme — 2012-04-05

We read with interest the letter to the Editor regarding our publication. We would like to provide the following comments. The authors suggest that worsening of respiratory function after initiating mechanical ventilation is caused by a decrease in the pulmonary blood flow and by a right-to-left shunting across the ductus arteriosus. This hypothesis is based on the theoretic calculation of ductal shunting, assuming that ductal flow is equal to the left ventricular outflow minus 2.7 multiplied by the superior vena cava flow. Indeed, we and others previously have shown that an estimate of total systemic blood flow can be derived from superior vena cava flow multiplied by 2.7. However, in these studies, the measurements were performed in preterm infants within the first 48 hours after birth. In the present study, the preterm infants were enrolled at a mean postnatal age of 14 days. Evidence exists that the superior vena cava flow/systemic blood flow ratio changes rapidly after birth. We previously reported a mean left ventricular outflow/superior vena cava ratio of 2.5 in preterm infants with hemodynamically significant persistent ductus arteriosus. Therefore, we believe that the ductal flow cannot be extrapolated from the left ventricular outflow and the superior vena cava flow measurements. In addition, the ductal flow was assessed directly by Doppler echocardiography in the present study: the direction of the ductus arteriosus shunting was strictly left to right before and after starting the mechanical ventilation. In no infant was the ductal shunting right to left.