Bypass Graft Surgery Research Articles

P2857Implantable cardioverter defibrillator and pacemaker lead extraction: is it safe to do it again?

Abstract Background/Introduction There are growing numbers of transvenous implantable devices for patients requiring permanent pacemakers (PPM) as well as Implantable Cardioverter Defibrillators (ICD). As such, there has been a concomitant increased need for lead extraction. Lead extraction is associated with increased morbidity and mortality (Hamid, 2010). Comparative outcomes of repeat lead extraction are not extensively studied. Purpose We compared demographics as well as major and minor adverse outcomes in patients undergoing first time vs. repeat lead extraction procedures. Methods In our single center study, 1278 extractions took place between January 2004 and December of 2018. Of these 1177 patients underwent PPM or ICD lead extraction for the first time; 101 patients underwent repeat extractions. Baseline characteristics including gender, history of coronary artery bypass graft (CABG) surgery, hypertension (HTN), systolic heart failure (HF) defined as ejection fraction <40%, hyperlipidemia (HLD), diabetes mellitus (DM), and coronary artery disease (CAD) were evaluated using chi-squared analysis. Adverse events, as defined by the 2017 HRS Expert Consensus Statement on Cardiovascular Implantable Electronic Device Lead Management and Extraction, were identified as major complications (death, cardiac arrest, cardiac perforation, coronary venous dissection, pericardial tamponade, or urgent cardiac surgery), and minor complications (coronary sinus dissection, pneumothorax, pocket bleeding requiring drainage, worsening tricuspid valve function, vegetation embolization, venous thrombosis, requirement of blood transfusion or lead migration). Results Comparing first time extractions vs repeat extractions, there was no significant difference in proportion of patients of female gender (32.4% vs. 28.3%, p=0.412), patients with prior CABG (23.0 vs. 23.4%, p=0.227), HTN (66.0% vs. 62.2%, p=0.462), HF (52.3% vs. 62.0%), HLD (39.6% vs 39.7%, p=0.682), DM (35.3% vs. 30.8%, p=0.387), or CAD (55.9% vs 56.0%, p=0.978). There was no significant difference in major complications (1.4% vs. 1.0%, p=0.749) and minor complications (3.5% vs 4.1%, p=0.741). Conclusion Patients undergoing repeat lead extractions showed very similar baseline demographics compared to first time lead extractions. Repeat extractions did not have increased rates of major or minor complications.

Skeletonisation contributing to a reduction of sternal wound complications: a retrospective study in OPCAB patients

BackgroundSternal wound complications (SWC) are a rare but potentially life-threatening complication after coronary artery bypass grafting (CABG) surgery. Especially the use of bilateral IMA (BIMA) grafts as opposed to single IMA (SIMA) grafts is associated with an increased risk of SWC. Skeletonised harvesting has been proposed to reduce this risk. The purpose of this study was to retrospectively investigate the effect of skeletonisation on SWC after off-pump coronary artery bypass grafting (OPCAB) in a centre with a high volume of off-pump procedures and high frequencies of BIMA.MethodsFrom January 2010 to November 2016, 1900 consecutive patients underwent OPCAB surgery at the University Hospitals of Leuven. The first group (n = 1487) received non-skeletonised IMA grafts, whereas the second group (n = 413) received skeletonised grafts. Optimal wound management was pursued in all patients. A new four-grade classification for SWC was developed. Incidence and grade of SWC as well as overall survival were assessed.ResultsAnalysis of diabetic patients showed a lower incidence of SWC in the skeletonised (12/141, 8.5%) compared to the non-skeletonised group (82/414, 19.8%) [odds ratio 0.46, 95% confidence interval (0.23;0.88), p = 0.019] as well as a lower grade [0.45 (0.24;0.871), p = 0.018]. There was no significant effect on overall survival [0.67 (0.19;2.32), p = 0.529]. Subanalysis of this population revealed that the observed effects were most prominent in patients receiving BIMA grafts, with 6/56 (10.7%) SWC in the skeletonised and 62/252 (24.6%) in the non-skeletonised group [0.37 (0.15;0.90), p = 0.028 for incidence], as well as a lower grade [0.36 (0.15;0.88), p = 0.025]. These advantages were not significant in diabetic patients receiving SIMA grafts nor in the full study population.ConclusionsThis study, using a more sensitive classification of SWC, shows in a large group of patients that, in combination with optimized wound management, the skeletonisation technique is associated with a clear reduction in the incidence and grade of SWC in diabetic patients receiving BIMA grafts. This encourages the extension of BIMA use in OPCAB to this risk population.

Prevalence of coronary artery disease risk factors in patients undergoing coronary artery bypass surgery in West Azerbaijan province

Background and aims: Coronary artery disease (CAD) is one of the main causes of death worldwide and coronary artery bypass grafting (CABG) surgery accounts for 1.4% of all operating room procedures. Considering the importance of the above-mentioned issue, the present study aimed to assess CAD risk factors in CABG patients to provide more accurate information for health authorities. Methods: To this end, data of all patients with isolated primary on-pump CABG were collected from March 2014 to March 2016. The major risk factors of CAD were recorded as a history of cigarette smoking, dyslipidemia, hypertension, diabetes mellitus (DM), advanced age, a family history of CAD, obesity, and male gender. Statistical analyses were performed by SPSS using a t test, as well as the chi-square and Fisher exact tests, and the P value less than 0.05 was considered statistically significant. Results: During a 24-month period, 895 patients underwent isolated primary on-pump CABG in the only open-heart surgery center in the West Azerbaijan province of Iran. The mean age of the patients was 60.4±10.3 years (within the range of 40 to 93 years). In addition, most of the patients amounting to 525 cases (58.7%) were in the age group of 55-70 years and had two or more risk factors. Further, 98.8% of males (age ≥45) and 68.2% of females (age ≥ 55) were old, and 73.3% and 26.7% of the patients were men and women, respectively. Furthermore, risk factors such as hypertension, cigarette-smoking, DM, hyperlipidemia, obesity, and family history were observed in 53.3%, 47.9%, 37.8%, 28.5%, 61.1%, and 19.3% of the patients, respectively. As regards gender, the prevalence of coronary risk factors like hypertension (60.7 vs. 50.6%, P=0.005), DM (51.9 vs. 32.6%, P=0.001), hypercholesterolemia (43.5 vs. 23%, P=0.001), and obesity (68.2 vs. 58.5%, P=0.005) were higher in women but other factors such as smoking (19.2 vs. 58.4%, P=0.001) and positive family history (14.6 vs. 21%, P=0.01) were higher in men. Conclusion: Overall, the prevalence of most risk factors was more common among under 55-year group, especially in women, and this is a warning for increasing CADs in the future

Incidental finding of PFO during cardiac surgery and implications - A dilemma in decision making

Introduction Patent foramen ovale (PFO) is common finding during coronary artery bypass graft (CABG) surgery. There is lack of data to help guide treatment decisions regarding incidental findings of PFO during CABG surgery. Certainly, the benefit versus risk equation seems to be a reasonable approach on individualized basis. Methods 67 years old female with history of unstable angina, no other comorbidities and normal preoperative Echocardiogram underwent elective CABG. Intraoperative TOE showed good biventricular function, no significant valvular abnormality and moderate size PFO with left-right shunt. The PFO was not treated as the patient was asymptomatic preoperatively. Immediately in postoperative period the patient was hypoxic. CTPA showed basal atelectasis, TOE demonstrated pericardial collection and reversal of the flow across the PFO. Percutaneous closure of PFO was considered but deemed inappropriate due to lack of evidence. Following discharge patient was readmitted with shortness of breath. She underwent a complicated redo-sternotomy for surgical removal of pericardial collection and PFO closure. Injury to the RV due to adhesion required femoral cannulation and led to compartment syndrome. Peri-operative TOE demonstrated moderate PFO with significant right-left shunt. Failure of mechanical ventilation wean mandated another review by cardiology and decision to percutaneously close the PFO was agreed. PFO closure was followed by immediate drop in oxygen requirement and facilitated immediate extubation and wean from ventilation. Discussion There is no evidence to suggest incidental PFO in patients undergoing cardiac surgery is linked to morbidity or mortality, and no evidence to support closure. One study showed that change from a planned procedure to include PFO closure increased risk of postoperative stroke with no long-term survival benefit. PFOs in patients with history of cryptogenic stroke are known to be larger (>4 mm) with longer tunnels (>1 cm) and that size and history of paradoxical embolism are major factor behind the surgeon's decision to close PFO. Conclusion Lack of strong evidence has led to our patient's unanticipated complication and longer hospital stay. Closure of PFO in asymptomatic patient should be decided on individual basis. Stronger evidence and recommendations are necessary to prevent complications.

Levosimendan Versus Milrinone in the Management of Impaired Left Ventricular Function in Patients Undergoing Coronary Artery Bypass Graft Surgery

Background: Patients undergoing cardiac surgery are at risk of postcardiotomy myocardial dysfunction. This condition causes delayed recovery, organ failure, prolonged intensive care unit and hospital stays, and an increased risk of mortality; these patients often require inotropic agent support. Levosimendan is a calcium sensitizer with a unique mechanism of action, binding to cardiac troponin C and enhancing myofilament responsiveness to calcium, increasing myocardial contraction without increasing myocardial oxygen consumption. Phosphodiesterase III inhibitors such as milrinone provide an alternative means of inotropic support by increasing the concentration of cyclic AMP and intracellular calcium. They also have vasodilatory effects. Objective: The aim of this study was the comparison between levosimendan versus milrinone regarding their effects on the hemodynamics, need for additional mechanical (intra aortic balloon pump) or pharmacological support to the heart, weaning from mechanical ventilation and duration of intensive care unit stay for patients after Off-Pump Coronary Artery Bypass Graft (OPCABG) surgery suffering from impaired left ventricular function (preoperative ejection fraction ≤ 40%). Methods: 60 patients between 40 and 70 years of both sexes with impaired left ventricular function (ejection fraction ≤ 40%), New York Heart Association (NYHA III & IV), undergoing elective Off-Pump Coronary Artery Bypass Graft (OPCABG) surgery were selected for this study. After induction of anesthesia, patients were randomly assigned to one of two equal groups each containing 30 patients: Group L (Levosimendan group) included patients who received levosimendan 0.1- 0.2 µg/kg/min. Started immediately with the induction of anesthesia. Group M (Milrinone group) included patients who received milrinone 0.4-0.6 µg/kg/min. Started immediately with the induction of anesthesia. In both groups, norepinephrine was titrated (8 mg norepinephrine in 50 ml saline) to keep mean arterial pressure MAP ≥ 70 mmHg. Hemodynamic findings included Preoperative and post ICU discharge ejection fraction, systemic and pulmonary artery pressures, systemic and pulmonary vascular resistance, cardiac output and stroke volume. Also laboratory findings included Serum lactate and Troponin I., in addition, to post operative findings were: Need for intra aortic balloon pump, time of weaning from the ventilator, days of ICU stay and appearance of drug allergy compared in both groups. Results: There was a significant increase in the ejection fraction in both groups that was greater in the levosimendan group. The decrease in pulmonary pressure in the levosimendan group was more significant than milrinone group. There was a gradual decrease in pulmonary and systemic vascular resistance in both groups with a more significant decrease in the levosimendan group. There was a gradual increase in cardiac output and stroke volume in both groups that was greater in the levosimendan group. Serum lactate gradually decreased in both groups with an insignificant difference; there was an increase in serum troponin I level in both groups which was more significant in the milrinone group. Weaning from mechanical ventilation and length of ICU stay was shown to be significantly shorter in time in the levosimendan group. Conclusion: Both levosimendan and milrinone caused a significant increase in cardiac output, stroke volume and ejection fraction, with a decrease in pulmonary and systemic vascular resistance. These effects improved cardiac performance by decreasing afterload and increasing cardiac inotropism. It was noticed that these effects were more significant with levosimendan than milrinone. Also, there was a decrease in ICU stay, mechanical ventilation timing and hospital stay with levosimendan than milrinone which decreased the costs of treatment for the patients.

Application of strain and other echocardiographic parameters in the evaluation of early and long-term clinical outcomes after cardiac surgery revascularization

BackgroundCoronary artery bypass graft (CABG) surgery is an effective therapeutic strategy for coronary heart disease (CHD). Myocardial longitudinal strain echocardiography with 2D speckle tracking could obtain ventricular function with better accuracy and reliability than the left ventricular ejection fraction.The aim of the study was to assess changes in left ventricular function in patients before and after surgical revascularization for a 24-month period of observation, using echocardiography with speckle tracking strain imaging. We searched for echocardiographic predictors of poor early and long-term outcome after CABG.MethodsWe enrolled 69 patients scheduled for elective coronary bypass grafting. Patients were divided into groups based on pre-operative systolic and diastolic parameters, depending on the GLS value and the E’ Lat and E/E’ value. The correlation between these parameters and early and long-term outcomes was analyzed.ResultsPreoperative EF was preserved in 86, 95% (60) patients. Pre-operative reduced GLS was observed in 73.91% (51) of patients and severely reduced in 31.88% (22).In the first post-operative 6-month period, we observed a significant decrease in the GLS. The GLS was a predictor of early postoperative outcome for intubation time, the inotropes use and length of ICU stay. Diastolic dysfunction was a predictor of the greater inotrope requirements.ConclusionsGlobal longitudinal strain and diastolic dysfunction parameters are a good predictors of worse early outcome after CABG.

Pericardial complications and postcardiac injury syndrome after cardiovascular implantable electronic device placement : Ameta-analysis and systematic review.

Postcardiac injury syndrome (PCIS) is an emerging condition including pericarditis with or without pericardial effusion after an injury to cardiac tissue. Data are lacking on its incidence and clinical predictors after cardiovascular implantable electronic device (CIED) placement. We therefore performed this meta-analysis to determine the incidence of PCIS. Medline, Embase, and Cochrane CENTRAL databases were searchedaccording to PRISMA guidelines from February 2007 to February 2017 for studies evaluating pericardial complications subsequent to CIED implantation. Primary outcome was the total number of cases of pericarditis, pericardial effusion, and cardiac tamponade documented. Of 2931 references, 22articles (enrolling 188,944 patients) were included. Pooled estimates from random-effects analysis showed an overall incidence of 5.82 per 1000 patients (95% confidence interval [CI], 4.33-8.17) at 30days, and 1.60 per 1000 (95% CI: 0.13-3.07) at 1year. Advanced age and prior coronary artery bypass graft (CABG) surgery were associated with increased rates of pericardial complications. Our analysis revealed that CIED implantations are associated with alow incidence (0.6%) of pericardial complications at 30days. Patients with advanced age and prior CABG are high-risk patients for pericardial complications.

Study to Evaluate the Efficacy of ASP1128 (MA-0217) in Subjects at Risk for Acute Kidney Injury Following Coronary Artery Bypass Graft (CABG) and/or Valve Surgery

Study to Evaluate the Efficacy of ASP1128 (MA-0217) in Subjects at Risk for Acute Kidney Injury Following Coronary Artery Bypass Graft (CABG) and/or Valve Surgery

The efficacy and safety of prophylactic use of levosimendan on patients undergoing coronary artery bypass graft: a systematic review and meta-analysis.

Prophylactic use of levosimendan in cardiac surgery remains controversial and no meta-analysis has been done exclusively about that in patients undergoing coronary artery bypass graft (CABG) surgery. We conducted this systematic review and meta-analysis of levosimendan in CABG using PubMed, Embase, Scopus, and Cochrane Library (till April 20, 2018). Two-hundred and forty manuscripts were identified and 21 randomized trials (1727 patients in total) investigating the effect of levosimendan on the patients undergoing CABG surgery were finally included in this analysis. We found that levosimendan was an effective, well-tolerated inotropic agent in CABG, which was associated with a significantly reduced mortality rate [odds ratio (OR) 0.43, 95% confidence interval (CI) (0.26, 0.71), p = 0.001, I2 = 0%] and postoperative atrial fibrillation [OR 0.50, 95% CI (0.26, 0.97), p = 0.04, I2 = 76%], but a higher incidence of hypotension [OR 2.26, 95% CI (1.05, 4.85), p = 0.04, I2 = 79%]. Subgroup analyses revealed that such a benefit was mainly observed in the isolated CABG, the preoperative administration, with-bolus and on-pump subgroups. More high-quality and well-designed prospective studies are needed to confirm or disprove our findings in future.

Outcome of Robot-Assisted Bilateral Internal Mammary Artery Grafting via Left Pleura in Coronary Bypass Surgery.

Studies are extremely limited for the investigation of the clinical outcome of da Vinci robot-assisted bilateral internal mammary artery (BIMA) grafting in coronary artery bypass grafting (CABG) surgery. This study aimed to explore the short-term outcome of da Vinci robot-assisted BIMA grafting through the left pleural space. Relevant data were collected from patients with multi-vessel coronary artery disease receiving two kinds of CABG: a group of patients receiving da Vinci robot-assisted CABG with BIMA grafting, and another group of patients receiving sternotomy CABG with BIMA grafting. Primary endpoints, which included cardiovascular and renal endpoints, were analyzed between the groups using the chi-square test, analysis of variance test, and Kaplan–Meier analysis. Compared with the conventional group (n = 22), the robotic group (n = 22) had a significantly longer operation time (12.7 ± 1.7 vs. 8.5 ± 1.5 hours; p < 0.01) and a marginally lower mean of serum creatinine at baseline (1.2 ± 0.3 vs. 2.0 ± 1.7 mg/dL; p = 0.04). Primary endpoints (5, 22.7% vs. 12, 54.5%; p = 0.03) and renal endpoints (1, 4.5% vs. 7, 31.8%; p = 0.02) at six months were significantly reduced in the robotic group compared with the conventional group. There were no differences in cardiovascular endpoints at six months between the groups (1, 4.5% vs. 0; p = 1.00). The data showed that da Vinci robot-assisted BIMA grafting was safe, with equal cardiovascular events and lowered renal events at six months, as compared to conventional sternotomy BIMA grafting, despite the longer procedure time. The short-term study suggests that da Vinci robot-assisted BIMA grafting may be considered a favorable surgical option for patients with severe coronary artery disease.

Pericardial closure with extracellular matrix scaffold following cardiac surgery associated with a reduction of postoperative complications and 30-day hospital readmissions

BackgroundA prospective, multi-center study (RECON) was conducted to evaluate the clinical outcomes of pericardial closure using a decellularized extracellular matrix (ECM) graft derived from porcine small intestinal submucosa.MethodsPatients indicated for open cardiac surgery with pericardial closure using ECM were eligible for the RECON study cohort. Postoperative complications and readmission of the RECON patients were compared to the patient cohort in the Nationwide Readmissions Database (NRD). Inverse probability of treatment weighting was used to control the differences in patient demographics, comorbidities, and risk factors.ResultsA total of 1420 patients at 42 centers were enrolled, including 923 coronary artery bypass grafting (CABG) surgeries and 436 valve surgeries. Significantly fewer valve surgery patients in the RECON cohort experienced pleural effusion (3.1% vs. 13.0%; p < 0.05) and pericardial effusion (1.5% vs. 2.6%; p < 0.05) than in the NRD cohort. CABG patients in the RECON cohort were less likely to suffer bleeding (1.2% vs. 2.9%; p < 0.05) and pericardial effusion (0.2% vs. 2.2%, p < 0.05) than those in the NRD cohort. The 30-day all-cause hospital readmission rate was significantly lower among RECON patients than NRD patients following both valve surgery (HR: 0.34; p < 0.05) and CABG surgery (HR: 0.42; p < 0.05). In the RECON study, 14.4% of CABG patients and 27.0% of valve patients had postoperative atrial fibrillation as compared to previously reported risks, which generally ranges from 20 to 30% after CABG and from 35 to 50% after valve surgery.ConclusionsPericardial closure with ECM following cardiac surgery is associated with a reduction in the proportion of patients with pleural effusion, pericardial effusion, and 30-day readmission compared to a nationwide database.Trial registrationNCT02073331, Registered on February 27, 2014.

PREVALENCE OF TRIGGERS FROM NON-PULMONARY VEIN SITES IN PATIENTS WITH PRIOR CORONARY ARTERY BYPASS GRAFTING OR MAZE PROCEDURE UNDERGOING CATHETER ABLATION FOR ATRIAL FIBRILLATION

Atrial fibrillation (AF), is seen in up to 40% of patients following coronary artery bypass graft (CABG) surgery and 5-25% of post-MAZE cases. However, the source of arrhythmia in this subset of AF population is not clearly defined yet. We sought to assess the prevalence of non-pulmonary vein (NPV)

The Effect of Preoperative Neutrophil-Lymphocyte Ratio On Quality of Life After Coronary Artery Bypass Graft (CABG) Surgery

Neutrophil-lymphocyte ratio (NLR) is an inexpensive and easily accessible inflammatory biomarker. Studies have shown the ability of NLR to predict poor outcome in many diseases. This study aimed to determine the relationship between NLR and cardiovascular risk factors, and duration of ICU and hospital stay in post CABG patients. 137 patients who underwent CABG between 2013 and 2017 with available preoperative neutrophil and lymphocyte counts were included in the study. NLR was found to be increased in patients who had prolonged intensive care unit (ICU) stay and hospital/ ward stay. Thus NLR can potentially be used to predict worse outcome.Keywords: Neutrophil-lymphocyte ratio; coronary artery bypass graft (CABG); mortality; length of stay (maximum 4 keywords) eISSN: 2398-4287 © 2019. The Authors. Published for AMER ABRA cE-Bs by e-International Publishing House, Ltd., UK. This is an open access article under the CC BYNC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer–review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers), ABRA (Association of Behavioural Researchers on Asians) and cE-Bs (Centre for Environment-Behaviour Studies), Faculty of Architecture, Planning &amp; Surveying, Universiti Teknologi MARA, Malaysia.DOI: https://doi.org/10.21834/e-bpj.v4i10.1628

Comparative study between minimally invasive direct coronary artery bypass graft and traditional coronary surgery via sternotomy

Comparative study between minimally invasive direct coronary artery bypass graft and traditional coronary surgery via sternotomy

EuroSCORE II Validation as a Method for Cardiac Surgery Risk Stratification in Mexico

Objective: To Validate the EuroSCORE II as a method for cardiac surgery risk stratification in Mexican adult population. Methods: We included adult patients undergoing to cardiac surgery, in order to determine the predictive value of EuroSCORE II on morbidity and mortality risk. Continuous variables are presented as mean ± SD or median with its interquartile range as appropriate; categorical variables were described as n, % or rate. To validate the EuroSCORE II scale, the assessment was done with Hosmer- Lemeshow (HL) test. In terms of discrimination, we used the features of the receiver operation characteristic (ROC) curves. Results: They were 704 patients, grouped into five categories: simple (one vessel) Coronary Artery Bypass Grafting (CABG) surgery, n= 299 (43%) cases. CABG revascularization (two or more vessels), n= 208 (30%). Double Procedure (CABG + valve replacement) 174 (25%) cases. Triple procedure (CABG + valve + aorta surgery) 23 (3.3%) patients. The mortality observed within 30 days of the surgery was 88 (12.5%). Meanwhile, the mean of the expected mortality predicted by EuroSCORE II was 3.63 ± 5.91 (95% CI: 3.19-4.06). The EuroSCORE II scale presented a good capacity for discrimination in the studied population reaching an area under the ROC curve of 0.821 (p &lt; 0.000, 95% CI: 0.772-0.871). A calibration for the scale measured through logistic regression with goodness of adjustment of Hosmer-Lemeshow was determined (χ2 = 17.74, p = 0.64). Conclusion: EuroSCORE II showed moderate discrimination ability in general. The scale can be useful to identify some problems in our hospital, however, the mortality rate might be underestimated. Key words: Euroscore II; Adult Cardiac Surgery; Surgical Risk

Outcomes of revascularizing operations on lower-limb arteries in patients with critical ischaemia and multifocal atherosclerosis

The purpose of this study was to evaluate the amputation-free survival rate and predictors of major adverse cardiovascular events (extracardiac and cardiac mortality, non-fatal myocardial infarction, non-fatal stroke) in patients with atherosclerotic occlusive-stenotic lesions of the femoropopliteal-tibial segment and critical ischaemia. We analysed the results of treating a total of 122 patients with atherosclerotic lesions of the superficial femoral artery and lower limb critical ischaemia. Of these, 35 patients had no lesions of other arterial basins, 24 patients presented with a concomitant lesion of the carotid basin, 41 subjects had lesions of the coronary basin, and 22 had lesions of the coronary and carotid basins. The patients were subjected to either bypass graft operation (n=75) or endovascular intervention (n=47). The evaluated outcome measures were amputation-free survival and the frequency of major adverse cardiovascular events. The average duration of follow up amounted to 38.2±4.3 months. The carried out multivariate logistic regression analysis demonstrated that the factors associated with lower limb amputation and the development of major adverse cardiovascular events were as follows: a concomitant lesion of the coronary (p=0.044) and coronary-carotid (p<0.05) basins, a history of endured myocardial infarction (p=0.003), a C-reactive protein level not less than 17.0 mg/l (p<0.05) and the value of the apolipoprotein B/A1 ratio above 1.0 (p=0.004).

Preoperative oral methadone for postoperative pain in patients undergoing cardiac surgery: A randomized double-blind placebo-controlled pilot

ABSTRACT Background Inadequately controlled sternotomy pain after cardiac surgery can lead to delayed recovery and patient suffering. Preoperative intravenous methadone is effective for reducing both postoperative pain and opioid consumption. Despite ease of administration, the effects of preoperative oral methadone are not well described in the literature. Aims This pilot study investigated the effect of preoperative oral methadone on pain scores, analgesia requirements, and opioid-induced side effects. Methods A randomized double-blind placebo-controlled model was used with sampling of patients undergoing sternotomy for isolated coronary artery bypass graft (CABG) surgery (ClinicalTrials.gov registration no. NCT02774499). Participants were randomized to receive oral methadone (0.3 mg/kg) or oral placebo prior to entering the operating room. The primary outcome was pain scores on a 0–10 Verbal Rating Scale. Secondary outcomes included morphine requirements using patient-controlled analgesia (PCA), time to extubation, level of sedation, and side effects such as nausea, vomiting, pruritus, hypoventilation, and hypoxia over a 72-h monitoring time. Results Twenty-one patients completed the study. Oral methadone did not reduce pain scores in the methadone group (P = 0.08). However, postoperative morphine requirement during the first 24 h was reduced by a mean of 23 mg in the methadone group (mean difference, −23; 99% confidence interval [CI], 37–13 mg; P < 0.005). No reduction in pain scores or PCA morphine was observed beyond 24 h postoperatively. There was no difference in incidence of opioid-related side effects between groups throughout the postoperative period. Conclusions Though preoperative oral methadone did not reduce pain scores, morphine requirements were reduced in the first 24 h post-CABG.

Poređenje rezultata rutinskog i selektivnog postavljanja epikardijalnog pejsinga: iskustvajednog centra od 237 pacijenata

Objective: Recently, the use of epicar-dial pacing wires (EPW) has become the standard of care for patients undergoing open-heart surgery (OHS) at many cardiovascular surgery centers. However, the routine use of EPWs after OHS is increasingly questioning due to their potentially lethal complications and limited efficacy. Here, we aimed to investigate the impact of EPW placement on in-hospital mortality and to compare the frequency of the EPW related complications in patients receiving routine or selective EPW placement after elective OHS. Methods: A total of 237 patients undergoing OHS in our clinic (ORDU UN¤VERSTY TRA¤N¤NG AND RESEARCH HOSP¤TAL) were enrolled in this study. Study subjects were randomly assigned to one of the groups: Routine or selective EPW placement. In the latter, EPWs were placed according to the presence of intraoperative bradycardia with hemodynamic compromise , nodal or junctional arrhythmias, atrioventri-cular block or ventricular tachycardia. Results: There were 95 patients (40 %) receiving routine EPW and 142 (60%) patients receiving selective EPW. Active pacing was performed or required in 13 patients (5.4%). Five of them were in routine EPW group and 8 were in the selective EPW group (p = 0.902). Active pacing requirement was similar in coronary artery bypass grafting and valvular surgery (5% vs. 9%, p = 0.712, respectively). Permanent pacing was required in any of the subjects. Complications related to EPW occurred in 17 patients receiving routine EPW and 2 patients receiving selective EPW (p &lt; 0.001). Routine EPW implantation was significantly correlated with the development of the complications (r = 0.309, p &lt;0.001). Conclusion: Our findings indicate that the number of patients requiring temporary pacing after OHS is quite low and implementing an EPW is associated with potentially hazardous complications. Selective EPW placement compared to routine EPW placement is associated with fewer postoperative complications.

On pump harvesting of Left Internal Mammary Artery (LIMA) in unstable patients undergoing coronary artery bypass grafting (CABG) is a safe operative strategy: A pilot study

Objective:To evaluate the clinical safety of left internal mammary artery (LIMA) harvesting in hemodynamically unstable patients after establishing cardiopulmonary bypass (CPB) in isolated coronary artery bypass graft (CABG) surgery.Methods:The prospective observational study was conducted at Chaudhry Pervaiz Elahi Institute of Cardiology, Multan, Pakistan, from December 2016 to August 2018. All patients undergoing isolated CABG surgery in which LIMA conduit was harvested after establishing cardiopulmonary bypass because of hemodynamic instability at induction of anaesthesia or during surgery were included in the study. Preoperative, operative and postoperative characteristics of the patients were recorded. Data was analyzed using SPSS 19.Results:In Forty nine patients including 39 male and 10 female, early CPB had to be established because of hemodynamic instability and afterwards LIMA was harvested. Out of 49, 30 patients presented with CCS class III angina. 37 (75.5%) patients were scheduled on elective coronary surgery waiting list. There were 39 (79.59%) patients who weaned off bypass on mild inotropic support and 4 (8.16%) patients needed IABP support. All patients had multi-vessel coronary artery disease. Mean number of grafts were 3.428±0.577, CPB time was 110.59±25.594 and hospital stay was 5.367±1.424.Conclusions:The study showed that LIMA can be safely harvested in unstable patients after establishing extracorporeal circulation and by using this operative strategy in patients who need urgent or emergent surgical coronary revascularization LIMA can be safely used as a conduit.

All CABG Patients Who Have No Contraindications: Do They Get Perioperative Beta Blockers?

New-onset postoperative atrial fibrillation (POAF) following Coronary artery bypass graft (CABG) surgery has been described in up to 15% to 40% of patients in the initial postoperative period. POAF is related with higher mortality, increased hospital resource utilization, postoperative extra ITU hours and hospital days, consequently increasing hospital-related budgets. Beta blocker administration decreases the rate of POAF from 30% - 40% to 12% - 16% after CABG. According to the EACTS (European Association of Cardiothoracic Surgery) guideline December 2006, β-Blockers should routinely be used as the first choice for the prophylaxis of atrial fibrillation (AF) in all patients undergoing cardiac surgery, if not contraindicated (IB). To compare the contemporary practice with the recommended standard retrospective data of consecutive 400 patients treated with isolated CABG between July 2015 and June 2017 were collected. Those patients who received β-blockers on the day of surgery or the following morning (Continued and Restarted on 1st POD) met the standard guidelines. Thus, according to the data (12% + 20%) 32% of the patients met the standard. To compare the rate of Postoperative Atrial fibrillation, we divided the patients into two groups. Group A, who followed the guideline (128 patients) and Group B, who resumed β-Blockers 48 hours onwards (272 Patients). In group A, only 8 patients developed postoperative AF whereas in group B 88 patients developed postoperative AF which is also statistically significant (P β-blockers use at perioperative period.