Open-heart Procedures Research Articles

The Diabetic Disadvantage: Historical Outcomes Measures in Diabetic Patients Undergoing Cardiac Surgery—The Pre-Intravenous Insulin Era

Seven percent of the United States population is diabetic. However, diabetics are two to five times more likely to develop cardiovascular disease and therefore populate 30% of open heart procedures in this country. In addition, it has been well documented that diabetic cardiac surgery patients are further disadvantaged with worse outcomes following those procedures. This has been termed the "Diabetic Disadvantage." To benchmark these specific disadvantages, we evaluated the short- and long-term outcomes for diabetics and nondiabetics undergoing coronary artery bypass graft (CABG), CABG/valve, and aortic or mitral valve replacement surgery before the broader acceptance and use of intravenous insulin infusions in this patient population in 2001. All such patient records (n = 1,369,961) from the Society of Thoracic Surgeons national database operated on between 1990 and 2000 were assessed for short-term outcomes. Ten-year survival was evaluated among 36,835 patients from the Northern New England Cardiovascular Disease Study Group longitudinal registry. The diabetic population was found to have higher rates of 30-day mortality, deep sternal wound infection, stroke, and longer length of stay than the nondiabetic population. In addition, diabetic patients had approximately two-fold worse 10-year survival. All differences were statistically significant (P < 0.001). In summary, The Diabetic Disadvantage in the pre-intravenous insulin era is characterized by worse short- and long-term outcomes for diabetic patients undergoing cardiac surgery in the United States and Canada.

Rationale for glycemic control in cardiac surgical patients: The portland diabetic project

Since 1987, the Portland Diabetic Project has enrolled >5000 patients with diabetes mellitus (DM)—including patients with noninsulin-dependent DM and patients with insulin-dependent DM—in a prospective nonrandomized study of the effects of perioperative insulin administration on morbidity and mortality after open-heart surgical procedures. In the early stages of the study, patients received SC insulin. In 1991, we instituted a continuous intravenous insulin (CII) protocol, which has been refined several times since its introduction. Our principal measure of glycemic control is the mean blood glucose value obtained by measuring glucose every 0.5 to 2 hours during the initial 3-day postoperative period (3-BG). There is a strong relationship between postoperative mortality and 3-BG value, even after adjusting for other clinical variables that influence mortality. The postoperative mortality rate was significantly lower among patients who received CII rather than SC insulin after coronary artery bypass grafting (CABG) or cardiac surgery of any type. We have also found that 3-BG is strongly associated with the risk of postoperative deep sternal wound infection (DSWI), and that treatment with CII significantly reduces the risk of infection. Our CII glucose protocol is slightly more expensive to administer than conventional SC insulin. However, when cost savings associated with a reduced rate of serious infection and reduced length of hospital stay are considered, CII results in total savings of >$4500 per patient. Widespread use of our CII protocol to manage perioperative hyperglycemia in patients with diabetes who undergo open-heart surgical procedures would result in substantial reductions in morbidity, mortality, and overall costs to the health care system.

Minimizing perioperative blood loss and transfusions in children

To summarize the physiology and pathophysiology relevant to perioperative blood loss in children. Strategies to reduce blood losses are reviewed.The literature was reviewed using the electronic library PUBMED and the Cochrane Database of Systematic Reviews. Relevant studies published in English or French with an English abstract are included. The following keywords were used: children, blood transfusion, surgical blood loss, erythropoietin, autologous blood, red blood cell saver, normovolemic hemodilution, desmopressin, aminocaproic acid, tranexamic acid, aprotinin, cardiac surgery, liver transplantation and scoliosis surgery.For patients with idiopathic scoliosis, predonation with or without the addition of erythropoietin is a safe and effective way to avoid the use of allogenic blood products. For open heart procedures: whole blood of less than 48 hr is helpful for children of less than two years of age undergoing complex procedures; tranexamic acid may be helpful for cyanotic heart disease and, to a lesser degree, for reoperations; while anti-kallikrein blood levels of aprotinin may both reduce the need for allogenic blood transfusions and improve postoperative oxygenation in infants.Reducing perioperative allogenic blood transfusions is possible in pediatric patients provided that prophylactic measures are adapted to age, disease and type of surgery.

A Multidisciplinary Approach with Reducing Cardiac Surgical Site Infections

BACKGROUND/OBJECTIVES: Despite adherence to evidenced-based practice recommendations, SSIs can still occur. The Cardiac Surgical Team, Infection Control & Prevention Department, and the Performance Improvement Department collaborated to implement best practices for reducing SSI morbidity and mortality in cardiac surgical patients. We proceeded to compare the Centers for Disease Control & Prevention (CDC) and the Surgical Care Improvement Project's (SCIP) best practices to our current practice. Additionally, process of care opportunities were identified from intense analyses involving cardiac surgical patients. Time was spent observing patient care in the Operating Room and Cardiac Surgical Intensive Care Unit. Opportunities to improve the correct timing, dosing, and documentation of antibiotics during the preoperative & intraoperative periods were found. METHODS: Buy-in from the Department of Anesthesia and Surgery Chiefs was obtained. A summary of hospital preoperative antibiotic timing data compared to best practices was presented to the members of the Departments of Anesthesia and Surgery. The practice of giving antibiotics “on-call” was discontinued; instead, the medication was administered in the Operating Room Holding Area. The Anesthesia Record was revised to highlight the preoperative antibiotic. Questioning if the preoperative antibiotic has been administered became part of the surgical time out process. The Cardiac Perfusionist assisted with antibiotic documentation on the Perfusion Record. Timers were placed in every operating room suite as a reminder to ensure the re-bolusing of selected antibiotics. Cefazolin 2 Grams was given preoperatively to all patients who weigh ≥200 pounds. Preoperative antibiotic timing and postoperative antibiotic discontinuation continued to be reviewed monthly for every case. Cardiac surgical infection surveillance continued for all open heart procedures. RESULTS: Pre-op antibiotic administration compliance within one hour before surgery was at 28.6% during December 2003 and has now been sustained at or near 100%. Use of appropriate antibiotics has been consistently 100% since October 2003. Surgical Site Infection Rates for Risk 1 CABG procedures, previously slightly greater than the 50th decile during 2002, is now below the 10th decile when compared to NNIS data. CONCLUSIONS: The Cardiac Surgical Team's acceptance/buy-in of the numerous recommendations came willingly. Operational issues at times were challenging. However, our multidisciplinary team was able to improve and sustain a high rate of performance to significantly reduce infection in the cardiac surgical patient. BACKGROUND/OBJECTIVES: Despite adherence to evidenced-based practice recommendations, SSIs can still occur. The Cardiac Surgical Team, Infection Control & Prevention Department, and the Performance Improvement Department collaborated to implement best practices for reducing SSI morbidity and mortality in cardiac surgical patients. We proceeded to compare the Centers for Disease Control & Prevention (CDC) and the Surgical Care Improvement Project's (SCIP) best practices to our current practice. Additionally, process of care opportunities were identified from intense analyses involving cardiac surgical patients. Time was spent observing patient care in the Operating Room and Cardiac Surgical Intensive Care Unit. Opportunities to improve the correct timing, dosing, and documentation of antibiotics during the preoperative & intraoperative periods were found. METHODS: Buy-in from the Department of Anesthesia and Surgery Chiefs was obtained. A summary of hospital preoperative antibiotic timing data compared to best practices was presented to the members of the Departments of Anesthesia and Surgery. The practice of giving antibiotics “on-call” was discontinued; instead, the medication was administered in the Operating Room Holding Area. The Anesthesia Record was revised to highlight the preoperative antibiotic. Questioning if the preoperative antibiotic has been administered became part of the surgical time out process. The Cardiac Perfusionist assisted with antibiotic documentation on the Perfusion Record. Timers were placed in every operating room suite as a reminder to ensure the re-bolusing of selected antibiotics. Cefazolin 2 Grams was given preoperatively to all patients who weigh ≥200 pounds. Preoperative antibiotic timing and postoperative antibiotic discontinuation continued to be reviewed monthly for every case. Cardiac surgical infection surveillance continued for all open heart procedures. RESULTS: Pre-op antibiotic administration compliance within one hour before surgery was at 28.6% during December 2003 and has now been sustained at or near 100%. Use of appropriate antibiotics has been consistently 100% since October 2003. Surgical Site Infection Rates for Risk 1 CABG procedures, previously slightly greater than the 50th decile during 2002, is now below the 10th decile when compared to NNIS data. CONCLUSIONS: The Cardiac Surgical Team's acceptance/buy-in of the numerous recommendations came willingly. Operational issues at times were challenging. However, our multidisciplinary team was able to improve and sustain a high rate of performance to significantly reduce infection in the cardiac surgical patient.

Percutaneous Valve Repair and Replacement

This issue of Circulation contains reports on the acute results of 2 approaches for percutaneous heart valve treatment.1,2 The introduction of nonsurgical, catheter-based approaches to the management of valvular heart disease is in a phase of rapid development. These 2 reports highlight both challenges and successes in phase I experience with these innovative therapies. Articles pp 842 and 851 Percutaneous valve therapy developed initially with aortic valve replacement, described by Andersen et al3 in 1992 in a swine model. These investigators fabricated a stent-mounted bioprosthetic valve and demonstrated that percutaneous implantation is feasible. Bonhoeffer et al4 reported the use of a stent-mounted bioprosthesis for pulmonic valve replacement in 2000. This achievement clearly marked the beginning of the era of percutaneous valve replacement therapy in patients. Pulmonic valve replacement with this percutaneous approach has been remarkably successful. To date, >100 patients have been treated, with only a single procedure-related mortality and good results in a population of pediatric patients with congenital heart disease who otherwise would face third or fourth open heart procedures. Percutaneous aortic valve replacement with a stent-mounted bioprosthetic valve device was initially reported by Cribier et al5,6 in 2002, with a growing experience since then. Numerous technical and clinical challenges have been encountered during phase I procedures for percutaneous heart valve therapy. The patient population for aortic valve replacement has been a group of patients considered high risk for surgery or nonsurgical candidates with numerous comorbid conditions. These patients have come to the cardiac catheterization laboratory with hypotension and low cardiac output. Under the best circumstances, they represent a great management challenge, even without the demands of new, complex percutaneous procedures. Early mortality in this group has been high, but there have also been stunning successes. Percutaneous aortic valve replacement was initially accomplished by …

Kein Opioidüberhang bei Patienten mit transdermalem Buprenorphin und Fast-Track-Anästhesie nach Eingriffen am offenen Herzen

Simultaneous use of opioids with a different pharmacological profile may lead to unexpected prolongation of effects. In an open label study possible overhang in post-operative respiratory effects and vigilance was determined in a group of patients (n = 22) carrying a transdermal buprenorphine patch for at least 2 months for treatment of chronic pain, undergoing a fentanyl-based fast-track enflurane anesthetic technique for open-heart operation. Data was compared with another randomised group (n = 21) undergoing similar open-heart procedures with no other opioid than fentanyl on board. Following induction with fentanyl and a barbiturate, depth of anesthesia with enflurane (Fi 0.5) was guided using the bispectral index (BIS). Additional doses of fentanyl were given when blood pressure and/or heart-rate increased 20% above pre-induction levels. Early postoperative extubation was initiated once the cardiovascular system was stable and there were no signs of respiratory impairment. Following a similar time of operation and anesthesia and a similar total dose of fentanyl (0.69 mg +/- 0.23 SD versus 0.67 mg +/- 0.16 SD), postoperatively, there were no significant differences between the buprenorphine- and the control group regarding the time till extubation (25.2 min +/- 6.1 versus 33.3 min +/- 5.0) and the arterial blood gases under oxygen inhalation (paO2 136 torr +/- 48 SD versus 128 torr +/- 35 SD; paCO2 43.3 torr +/- 3.3 SD versus 41.9 torr +/- 1.2 SD and the post-anesthetic vigilance and recovery score (6.8 +/- 1.0 versus 7.5 +/- 0.8) 60 minutes after end of anesthesia. Contrary to the control group, there was a lower and significant (p < 0.01) incidence of PONV in patients with transdermal buprenorphine. Patients using a buprenorphine patch for the relief of chronic pain cannot be regarded as opioid naïve. Due to adaptive mechanisms and the development of tolerance, there is no prolongation of the respiratory depression induced by intraoperative fentanyl. Long-term use of transdermal buprenorphine does not lead to potentiation or prolongation of opioid effects in cardiac surgery patients.

Coronary Artery Bypass Surgery in a Patient with a Functional Single Lung

Destroyed lung and pneumonectomy are associated with anatomic and physiologic changes that may interfere with the conduct of subsequent open heart surgery. Here we report a case of an autopneumonectomized patient who required open heart surgery. The preoperative, intraoperative and postoperative management of this patient was unique. Open heart procedures on patients with a single lung can be performed with acceptable operative mortality and morbidity.

Update on Pediatric Perfusion Practice in North America: 2005 Survey

The devices and techniques used for pediatric cardiopulmonary bypass (CPB) undergo continuous change. New techniques and clinical comparisons of devices are frequently reported in the literature; however, information about the extent to which these techniques and devices are adopted into clinical practice at pediatric heart centers are not well described. We conducted a mail survey of North American pediatric cardiac surgery centers to gain perspective on the extent to which various devices and techniques were used for CPB along with program demographic data. In January 2005, surveys were mailed to 180 North American open heart centers. The survey was nearly identical in format and content to three earlier surveys completed in 1989, 1994, and 1999, with the exception that new questions were added to address new techniques and devices that have emerged over the years. Responses were received from 76 hospitals, for an overall response rate of 42%. Of the responding centers, 53 were performing pediatric open heart surgery and 23 were not. Twenty centers performed only pediatric open heart surgery, and 33 performed both pediatric and adult open heart surgery. The mean pediatric annual caseload of responding centers was 195 procedures/yr (range, 20–650 procedures/yr; median, 154 procedures/yr). A total of 9943 pediatric open heart procedures were performed at responding centers in 2004. Most of the centers surveyed reported use of an open venous reservoir system (88%), use of roller pumps (90%), and use of arterial line filtration (98%). Most centers used circuits that have surface treatments with heparin or some other surface-modifying agent (74%). There has been an increase in the use of all types of safety devices. Modified ultrafiltration is used at 75% of the centers surveyed. Centers reported an increase in the availability of all types of cardiac support devices including extracorporeal membrane oxygenation for postcardiotomy cardiac support (90%). This survey provides an overview of clinical practice in 2004. The series of surveys document the historical progression of clinical practice over the past 16 years. Practice surveys may also be useful for identifying gaps between evidence-based knowledge and clinical practice. These surveys document the diffusion of innovation related to CPB during the past 16 years and areas of variation in practice that need further study.

Should Coronary Artery Bypass Grafting Be Regionalized?

Should Coronary Artery Bypass Grafting Be Regionalized?

Markers of hepatitis viruses and human T-lymphotropic virus types I/II in patients who have undergone open-heart surgery: Evidence of increased risk for exposure to HBV and HEV

Background Open-heart procedure is characterized by a high-risk for contracting blood-borne infections. We evaluated the prevalence of several markers of hepatitis viruses (B–E) and human T-cell lymphotropic virus types I/II (HTLV-I/II) in a consecutive series of patients who had undergone open-heart surgery. Methods 204 patients and 158 selected age- and sex-matched healthy volunteers were investigated. Samples were collected at least 6–12 months postoperatively. Commercial enzyme immunoassays and confirmatory immunoblot assays for HCV, HEV and HTLV-I/II were used. Results None of the subjects tested positive for antibodies to HTLV-I/II. Prevalence of markers of past HBV infection and antibodies to HEV (anti-HEV) were higher in patients than in healthy controls (anti-HBc: 45.1% vs. 31%, p = 0.009; anti-HBs: 31.9% vs. 22.2%, p = 0.02; anti-HBe: 32.4% vs. 10.1%, p = 0.000; anti-HEV: 5.4% vs. 0%, p = 0.008). HBsAg and antibodies to HCV did not differ between the groups. Conclusions HTLV, HBsAg and HCV infection markers did not differ between patients and healthy controls. However, patients had significantly increased prevalence of markers of previous HBV infection suggesting that an intensive vaccination schedule against HBV preoperatively might be helpful in minimizing the risk. The increased prevalence of anti-HEV in cardiac patients requires further investigation. Prospective studies are needed in order to definitely address whether the high prevalence of exposure to HBV and HEV infections in patients who had undergone open-heart surgery is procedure-related or not and whether it has any impact on morbidity of these patients.

Improvement in cost-effectiveness and customer satisfaction by a quality management system according to EN ISO 9001:2000

The implementation of a quality management system (QMS) according to EN ISO 9001:2000 has proven to be possible for cardiac surgery departments. However, it remains unclear if a QMS can help to improve quality as indicated by cost-effectiveness and customer satisfaction. To control costs for medical goods and laboratory investigations an internal control system for the allocation of resources was implemented. Laboratory costs and medical goods per open heart procedure were investigated in the years 2000 to 2003. In terms of customer satisfaction, repeated questionnaire-based evaluation of referring physicians was obtained from 2001 to 2003 and the influence of repeated interventions on various aspects of communications was investigated. Costs of medical goods could be reduced by 6.1%, and for laboratory investigations by 35% per operation. Additionally, customer satisfaction could be increased efficiently with respect to accessibility and postoperative communication. By the introduction of a process based QMS, efficient control of the costs of medical goods and laboratory investigations could be achieved. Once a year repeat evaluation of satisfaction of advising physicians has proven to be a valuable tool in the process of continuous improvement.

Invited commentary

Kubota and colleagues [1] report their experimental experience with atrial fibrillation surgery on the beating heart. They confirm the potential for an alternative energy source, an infrared coagulator, and for the modified maze procedure. The article represents a contribution to the general surgical question: “How should we treat a patient with chronic atrial fibrillation undergoing open heart procedure?” Or more precisely, the question is: “What is the best surgical method to treat a patient with chronic atrial fibrillation?”

Automated Knot Tying For Fixation in Minimally Invasive, Robot-Assisted Cardiac Surgery

Cardiovascular disease (CVD) is perhaps the most significant worldwide health issue. While open-heart surgery remains the predominant treatment, significant advancements have been made in minimally invasive surgery (MIS) and minimally invasive robot-assisted (MIRA) surgery. MIRA techniques offer many advantages over open-heart procedures and have extended the capabilities of MIS. However, these benefits come at the cost of increased operating times due to time spent tying knots. The additional bypass time limits patient access and is the most significant barrier to the adoption of MIRA techniques. This research seeks to overcome this barrier by designing a device for MIRA cardiac procedures that automates the knotting of sutures. If this task can be automated while ensuring the delivery of high-quality knots, great progress can be made in transforming the field. MIRA cardiac procedures can move from novel procedures performed by a select group of surgeons on a limited pool of patients to a viable alternative available to the majority of patients with CVD. In this research we propose a design for a self-contained device that delivers a locking knot. Results suggest that consistent knots can be delivered at a time savings of 12.5% and 26.4% over manual knots for trained and untrained users of a surgical robot, respectively.

No potentiation of fentanyl by use of transdermal buprenorphine in patients undergoing fast-track anesthesia for open-heart surgery

Simultaneous use of opioids with a different pharmacological profile during anesthesia may lead to unexpected prolongation of effects. In addition, long-term use of transdermal buprenorphine may result in a reduced sensitivity to opioid anesthesia. In a prospective study, possible overlap of opioid effects and vigilance was determined in a group of patients (n = 22) using a buprenorphine patch for at least two months for treatment of chronic pain, and undergoing fentanyl-based fast-track enflurane anesthesia for open-heart surgery. The patients using buprenorphine were compared with a control group (n = 21) undergoing similar open-heart procedures with no opioid other than fentanyl on board. Aside from time to extubation, total dose of fentanyl, postoperative blood gases, and vigilance assessment score were used to determine possible overlap of opioid effects and/or development of opioid tolerance in the buprenorphine group compared to the control group. Both groups had similar operation and anesthesia times and comparable doses of fentanyl (0.69 mg +/- 0.23 vs. 0.67 mg +/- 0.16 SD). There was no significant difference in postoperative arterial blood gases (PaO2 136 +/- 48 torr vs. 128 +/- 35 torr SD; PCO2 43.3 +/- 3.3 torr vs. 41.9 +/- 1.2 torr SD), time until extubation (27 +/- 22 min vs. 33 +/- 24 min), and postanesthetic vigilance and recovery score (6.8 +/- 1.0 vs. 7.5 +/- 0.8, arbitrary units) between the two groups. Because of adaptive mechanisms and the development of tolerance in patients using buprenorphine, respiratory depression or sedation does not project into the postoperative period. The significant (p < 0.05) lower incidence of nausea and emesis in patients with transdermal buprenorphine owes to the development of tolerance to these opioid-related side effects.

Lessons Learned from the Development of a New Hybrid Strategy for the Management of Hypoplastic Left Heart Syndrome

Despite improvements in surgical techniques and perioperative management, the overall results of traditional staged palliation for hypoplastic left heart syndrome (HLHS) remain suboptimal. We report the evolution of a hybrid strategy in 34 patients coupling innovative surgical and transcatheter techniques that requires one open-heart procedure to reach a Fontan completion. Experience has led to modifications in technique, timing of procedures, and follow-up. Current initial palliation is by intraoperative, off-pump, placement of bilateral pulmonary artery bands and a PDA stent. Transcatheter creation of an unrestricted atrial septal defect is performed when necessary. Follow-up includes weekly cardiology assessment, including echocardiography with a surveillance catheterization performed at 6 weeks. At 3-6 months a comprehensive stage 2 procedure (elements of traditional stages 1-3) is performed. At 2 years, transcatheter Fontan completion with a covered stent is performed. Initial hybrid stage 1 was from August 2001 to December 2004 and included 29 newborns (1.8-4.2 kg). There were five hospital deaths and three interstage deaths. Procedural and interstage deaths were eliminated in the latter half of the experience. Comprehensive stage 2 included 18 patients. There were four deaths; two patients who died were brought urgently to operation. Transcatheter Fontan completion included 5 patients (not from the initial 29); there were no deaths and all returned home in 24 hours. With this strategy there is one exposure to cardiopulmonary bypass, aortic cross-clamping, and circulatory arrest. There was a significant learning curve, which is highlighted. This initial experience warrants further investigation to determine whether this hybrid strategy will yield better short- and long-term outcomes.

Lessons Learned from the Development of a New Hybrid Strategy for the Management of Hypoplastic Left Heart Syndrome

Despite improvements in surgical techniques and perioperative management, the overall results of traditional staged palliation for hypoplastic left heart syndrome (HLHS) remain suboptimal. We report the evolution of a hybrid strategy in 34 patients coupling innovative surgical and transcatheter techniques that requires one open-heart procedure to reach a Fontan completion. Experience has led to modifications in technique, timing of procedures, and follow-up. Current initial palliation is by intraoperative, off-pump, placement of bilateral pulmonary artery bands and a PDA stent. Transcatheter creation of an unrestricted atrial septal defect is performed when necessary. Follow-up includes weekly cardiology assessment, including echocardiography with a surveillance catheterization performed at 6 weeks. At 3-6 months a comprehensive stage 2 procedure (elements of traditional stages 1-3) is performed. At 2 years, transcatheter Fontan completion with a covered stent is performed. Initial hybrid stage 1 was from August 2001 to December 2004 and included 29 newborns (1.8-4.2 kg). There were five hospital deaths and three interstage deaths. Procedural and interstage deaths were eliminated in the latter half of the experience. Comprehensive stage 2 included 18 patients. There were four deaths; two patients who died were brought urgently to operation. Transcatheter Fontan completion included 5 patients (not from the initial 29); there were no deaths and all returned home in 24 hours. With this strategy there is one exposure to cardiopulmonary bypass, aortic cross-clamping, and circulatory arrest. There was a significant learning curve, which is highlighted. This initial experience warrants further investigation to determine whether this hybrid strategy will yield better short- and long-term outcomes.

Robotic Surgery, the First 100 Cases: Where Do We Go from Here?

Abstract Background: Since the robot-assisted cardiac surgery program at this center was initiated in September 1998 the results have been regularly critically evaluated. We report a retrospective review of the first 100 robotic procedures and their evolution. Methods: Between September 1998 and May 2001, 146 patients underwent robot-assisted procedures. All procedures were performed using the Aesop robotically controlled camera or the Zeus robotic system. A harmonic scalpel was used for all internal thoracic artery (ITA) dissections whether the dissections were performed manually or with the Zeus robotic system. Results: There were 123 closed-heart and 23 open-heart procedures, which included 8 atrial-septal defect repairs, 11 mitral valve repairs, 4 mitral valve replacements, 57 Aesop ITA takedowns, 68 Zeus ITA takedowns, and 13 totally endoscopic coronary artery bypass grafts. Graft patency in Aesop and Zeus ITA takedown groups was 96%. All the patients were New York Heart Association class I after their procedures. Conclusion: With the development of surgical robots, it has been possible to perform endoscopic cardiac surgery for selected cases. Future directions will be demonstrated, including telementoring, telesurgery, and Zeus-assisted initiatives in cardiac surgery and other surgical disciplines.

Clinical Effectiveness of Leukocyte Filtration During Cardiopulmonary Bypass in Patients with Chronic Obstructive Pulmonary Disease

Background We tested the hypothesis that leukocyte filtration during pulmonary reperfusion preserves pulmonary function and results in improved oxygenation after cardiopulmonary bypass (CPB) in patients with chronic obstructive pulmonary disease (COPD). Methods In a prospective, randomized study, the treatment group consisted of 20 patients with COPD from consecutive open-heart procedures. A primed leukocyte filter was connected to the arterial line downstream of the standard arterial filter but was excluded from circulation. Circulated blood was directed through the leukocyte filter approximately 10 minutes before aortic cross-clamp removal and at early reperfusion for up to 30 minutes. These patients were compared to 20 additional COPD patients (controls) on whom systemic leukocyte filtration was not used during open-heart surgery. Results There was no significant difference in gender, age, left ventricular ejection fraction, type of procedure, aortic cross-clamp time, perfusion time, preoperative FEV 1 and preoperative respiratory index (Pa o 2/FiO 2 ratio) between treatment and control groups. The respiratory index changed in the treatment group by +9.8% of baseline after completion of CPB, by −14.2% upon arrival in the intensive care unit (ICU), and by −19.6% 12 hours later, whereas in the control group, it changed by −14.5% ( p < 0.05), −27.7%, and −24%, respectively. Leukocyte-depleted patients required shorter intubation time (20.4 ± 16.1 hours), ICU stay (46.2 ± 40.1 hours) and length of hospitalization (8.3 ± 2.8 days) than controls (29.5 ± 21.9 hours, p < 0.05; 75.5 ± 34.9 hours, p < 0.005; and 10.4 ± 3.5 days, p < 0.05, respectively). Surgical (30-day) mortality was zero in both groups. Conclusions In COPD patients having CPB, systemic leukocyte depletion at early reperfusion was associated with better oxygenation, shorter intubation time, and shorter ICU and hospital stays. Leukocyte filtration during CPB most likely preserves pulmonary function by ameliorating pulmonary reperfusion injury.

Preoperative international normalised ratio (INR) and bleeding during open-heart procedure

In order to eliminate the complication of bleeding following open heart surgery we studied a group of patients in whom the pre-operative international normalized ratio (INR) was estimated. Those with INR less than 2 had less bleeding. Those with INR between 2 nd 2.5 need individualized management and may require aprotinin.

Les anévrismes mycotiques de l'aorte ascendante : à propos de deux cas

Infection in the vascular tree has been proved to be one of the greatest challenges for cardiovascular surgeons. Mycotic aneurysm of the ascending aorta is unusual, life threatening pathologic entity and develops mainly after open heart procedure. We report two cases of mycotic aneurysm of the ascending aorta occurring after prosthetic replacement of the aortic valve.