Postoperative Cardiac Tamponade Research Articles

SURGERY OF TYPE A AORTIC DISSECTIONS: WHAT HAS CHANGED? SINGLE CENTER EXPERIENCE

Abstract Introduction Our knowledge on type A aortic dissection (ATAAD) has evolved, and there are some differences in surgical approach. In this paper, we focused on what changed in the surgical treatment of ATAAD and on the impact of these changes on patients’ survival, analyzing our center experience and comparing it with literature latest evidences. Materials and Methods From 2010 to 2022, 342 consecutive patients underwent surgery for Acute Type A Aortic dissection at our institution. In order to identify changes in these patients’ management over time, we divided our population in two groups according to the year of surgery: Group A before 2016 (146 patients) and Group B after 2016 (196 patients). Results Patients from Group B (after 2016) showed more comorbidities and a worse clinical presentation than patients from Group A (chronic kidney disease 9.2% vs 2.1% p=0.006, neurological deficit on admission 8.7% vs 0% p < 0.001, cardiac tamponade 12.2% vs 0.7% p < 0.001, and pre–operative catecholamine support 4.1% vs 0% p=0.012). Also of pre–operative malperfusion was more frequent (coronary 6.6% vs 0% p < 0.001 and peripheral 6.6% vs 0% p < 0.001). In Group B in 70.4% of the population the circulatory arrest with antegrade selective cerebral perfusion was used vs 30.8% in Group A (p < 0.001) and we find a bigger percentage of emiarch replacement (43.4% vs 23.3% P=0.008) and total arch replacement (27% vs 13.7% p=0.017) than in Group A. In–hospital mortality resulted to be 10.2% with no differences between the groups. Neurological events (p<0.001) and post–operative dialysis (p=0.036) were more frequent in Group B. On the other hand, in Group A post–operative cardiac tamponade (9.65 vs 3.1% p=0.007) and red blood cells transfusions were higher. Conclusions Nowadays surgery is performed on more critical patients with higher surgical risk and the tendency is to perform more complex operations with replacement of a largest portion of the diseased aorta in order to reduce reintervention rate. Recently, clinical studies and guidelines highlighted the importance of creating a multidisciplinary aortic team to discuss and manage these patients in order to assure the best treatment options to each patient and to reduce mortality and morbidity.

Posterior pericardiotomy and the prevention of post-operative atrial fibrillation and cardiac tamponade in isolated coronary artery bypass grafting – A retrospective analysis

BackgroundPost-Operative Atrial Fibrillation (POAF) is the most frequent complication of cardiac surgery and is associated with reduced survival, increased rates of cognitive changes and cerebrovascular accidents, heart failure, renal dysfunction, infection, length of stay and hospital costs. Cardiac tamponade although less common, carries high morbidity and mortality. Shed mediastinal blood in the pericardial space is a major source of intrapericardial oxidative stress and inflammation that triggers POAF. The utilisation of a posterior pericardiotomy (PP) aims to shunt blood from pericardium into the pleural space and have a role in the prevention of POAF as well as cardiac tamponade.Methods2168 patients had undergone isolated Coronary Artery Bypass Grafting at Royal Hobart Hospital from 2008 to 2022. They were divided into PP group vs. control group. Patient baseline demographics, intraoperative data and post-operative outcomes were reviewed retrospectively.ResultsTotal incidence of new POAF and cardiac tamponade was 24% and 0.74% respectively. Primary outcome of both the incidence of POAF (20.2% vs. 26.3%, p < 0.05) and Cardiac Tamponade (0% vs. 1.1%, p < 0.05) were less in the pericardiotomy group. A subgroup analysis of patients with recent myocardial infarction showed reduced incidence of POAF in the PP group (p < 0.05). Increasing age, Body Mass Index, poor left ventricular ejection fraction (EF < 30%) and return to theatre were independent predictors of developing POAF. There were similar rates of return to theatre for bleeding however, no cases of tamponade in the pericardiotomy group. There were no complications attributable to left posterior pericardiotomy and the time added to the duration of surgery was minimal.ConclusionPosterior pericardiotomy is associated with a significant reduction in the incidence of POAF and cardiac tamponade which is safe and efficient.

Transcatheter Aortic Valve Implantation Using the Transcervical Vascular Access (from a 7-Year Experience from a Swiss Tertiary Center)

The gold-standard transfemoral (TF) access for transcatheter aortic valve implantation (TAVI) is not suitable in 10% to 15% of patients, and alternative accesses are needed. Studies have suggested that the transcervical (TC) access might yield outcomes comparable to the TF access. In our center, TC-TAVI is the first-line alternative to TF-TAVI. We herein present our 7-year experience regarding the use of the TC access in TAVI. We included all consecutive patients referred for TC-TAVI between January 1, 2016 and December 31, 2022. Data regarding the patients' characteristics,perioperative and 30-day outcomes were prospectively collected. Patients were separated into 2 temporal groups (group 1: January 1, 2016 to June 30, 2019; group 2: July 1, 2019 to December 31, 2022) to assess the changes of their characteristics and outcomes over time. A total of 95 patients were included, with more belonging to group 2 (n=56 vs n=39 in group 1). Patients in group 2 were significantly younger (81.0 [interquartile range 77.0 to 87.0] vs 89.0 [interquartile range 83.0 to 92.0] years, p <0.001) and had a higher prevalence of hypertension (87.5% vs 66.7%, p=0.028) and chronic pulmonary disease (35.7% vs 15.4%, p=0.029). There was no significant difference regarding other co-morbidities or surgical scores. All-cause mortality and the risk of stroke at 30days were low and similar (group 2 vs group 1, 3.6% vs 2.5%, p=0.787 and 1.8% vs 0%, p=0.397, respectively), as were the risks of permanent pacemaker implantation, postoperative acute kidney injury, cardiac tamponade, life-threatening bleeding, and major vascular complications. In conclusion, the use of the TC access increased over time. The rates of adverse events did not change, despite patients from mid-2019 onward having slightly more co-morbidities.

Emergent Bedside Resternotomy: An Innovative Simulation Model for Training Pediatric Cardiac Intensive Care Teams

AbstractCardiac tamponade after cardiac surgery is a life-threatening event that requires simultaneous resuscitation and emergent resternotomy by the intensive care team. A simulated scenario using an innovative mannequin with sternotomy wound has the capability of reproducing cardiac arrest associated with postoperative tamponade. We evaluated the validity of this mannequin to investigate the confidence level and crisis resource management skills of the team during bedside resternotomy to manage postoperative cardiac tamponade. The simulation scenario was developed using the sternotomy mannequin for a pediatric cardiac intensive care unit (CICU) team. The case involved a 3-year-old male, intubated, and mechanically ventilated after surgical repair of congenital heart disease, progressing to cardiac arrest due to cardiac tamponade. We conducted a formative learner assessment before and after each scenario as well as a structured, video debriefing following each encounter. The simulation was repeated in a 6-month interval to assess knowledge retention and improvement in clinical workflow. The data were analyzed using student t-test and chi-square test, when appropriate. Of the 72 CICU providers, a significant proportion of providers (p &lt; 0.0001) showed improved confidence in assessing and managing cardiac arrest associated with postoperative cardiac tamponade. All providers scored ≥3 for the impact of the scenario on practice, teamwork, communication, assessment skills, improvement in cardiopulmonary resuscitation, and opening the chest and their confidence in attending similar clinical situations in future. Most (96–100%) scored ≥3 for the perception on the realism of mannequin, the scenario, reopening the sternotomy, and level of stress. Time to diagnosis of cardiac tamponade (p = 0.004), time to the first dose of epinephrine (p = 0.045), and median number of interruptions to chest compressions (p = 0.006) all significantly decreased between the two sessions. Time to completion of resternotomy improved by 81.4 seconds; however, this decrease was not statistically significant. Implementation of a high-fidelity mannequin for postoperative cardiac tamponade simulation can achieve a realistic and reproducible training model with positive impacts on multidisciplinary team education.

Comparison of Pericardiocentesis in Post-Cardiac Surgery and Nonsurgical Patients with Pericardial Tamponade.

IntroductionThere are several approaches for pericardiocentesis. However, there is no definite suggestion about puncture location after cardiac surgery. The purpose of this study is to examine whether there is any difference regarding puncture location during pericardiocentesis in postoperative cardiac tamponade comparing to nonsurgical cardiac tamponade.MethodsWe retrospectively analyzed patients who had undergone pericardiocentesis from August 2011 to December 2019. Patients were examined in two groups, nonsurgical and postsurgical, based on the etiology of pericardial tamponade. Clinical profiles, echocardiographic findings, and procedural outcomes were identified and compared.ResultsSixty-eight pericardiocenteses were performed in this period. The etiology of pericardial effusion was cardiac surgery in 27 cases and nonsurgical medical conditions in 41 cases. Baseline demographic variables were similar between the surgical and nonsurgical groups. Loculated effusion was more common in the postsurgical group (48.1% vs. 4.9%, P<0.001). Maximal fluid locations were different between the groups; right ventricular location was more common in the nonsurgical group (36.6% vs. 11.1%, P=0.02), while lateral location was more common in the postsurgical group (12.2% vs. 40.7%, P=0.007). Apical drainage was more frequently performed in the postsurgical group compared to the nonsurgical group (77.8% vs. 53.7%, P=0.044).ConclusionApical approach as a puncture location can be used more frequently than subxiphoid approach for effusions occurred after cardiac surgery compared to nonsurgical effusions. Procedural success is prominent in this group and can be the first choice of treatment.

Risk analysis for early mortality in emergency acute type A aortic dissection surgery: experience of Tokyo Acute Aortic Super-network.

We investigated the various pre- and postoperative complications related to early (30-day) mortality after open surgery for acute type A aortic dissection. Data from the Tokyo Acute Aortic Super-network database spanning January 2015 to December 2017 were retrospectively reviewed. Pre- and postoperative factors related to early postoperative mortality were assessed in 1504 of 2058 (73.0%) consecutive patients [age: 66.6 (SD: 13.5) years, male: 52.9%] who underwent acute type A aortic dissection repair. The early mortality rate following surgical repair was 8.9%. According to multivariable analysis, male sex [odds ratio (OR) 1.670, 95% confidence interval (CI) 1.063-2.624, P = 0.026], use of percutaneous circulatory assist devices (n = 116, 7.7%) including extracorporeal membrane oxygenators or intra-aortic balloon pumps (OR 4.857, 95% CI 2.867-8.228, P < 0.001), shock (n = 162, 10.8%) (OR 3.06, 95% CI 1.741-5.387, P < 0.001), cardiopulmonary arrest (n = 41, 2.7%) (OR 7.534, 95% CI 3.407-16.661, P < 0.001), coronary ischaemia (n = 36, 2.3%) (OR 2.583, 95% CI 1.042-6.404, P = 0.041) and cerebral ischaemia (n = 59, 3.9%) (OR 2.904, 95% CI 1.347-6.261, P = 0.007) were independent preoperative risk factors for early mortality, while cardiac tamponade (n = 34, 2.3%) (OR 10.282, 95% CI 4.640-22.785, P < 0.001), cerebral ischaemia (n = 80, 5.3%) (OR 2.409, 95% CI 1.179-4.923, P = 0.016) and mesenteric ischaemia (n = 15, 1.0%) (OR 44.763, 95% CI 13.027-153.808, P < 0.001) were independent postoperative risk factors. Not only critical preoperative conditions but also postoperative cardiac tamponade and vital organ ischaemia are risk factors for early mortality after acute type A aortic dissection repair.

Effectiveness of posterior pericardiotomy in preventing cardiac tamponade and effusion pericarditis in the early period after interventions on the thoracic aorta

Background. Interventions on the thoracic aorta involving prolonged artificial circulation, clamping of the aorta and extensive dissection of the mediastinal structures are associated with a higher incidence of pericardial effusion and cardiac tamponade compared to other interventions. We suggest that routine implementation of posterior pericardiotomy may significantly affect the incidence of postoperative pericardial effusion syndrome and cardiac tamponade after interventions on the thoracic aorta.Aim. Evaluation of the effectiveness of posterior pericardiotomy regarding the development of cardiac tamponade, effusion pericarditis and the postoperative course of patients in the early period after interventions on the thoracic aorta.Methods. We conducted a retro- and prospective study that included 100 patients with thoracic aorta pathologies who were operated on in the cardiac surgery department of clinic from 2017 to 2020. All subjects were divided into two groups: a treatment group of 40 patients who underwent routine posterior pericardiotomy, and a control group of 60 patients without posterior pericardiotomy but with standard installation of postoperative drains. Assessment of the effect of posterior pericardiotomy on pericardial effusion, cardiac tamponade and the early postoperative period was conducted on the basis of transthoracic echocardiography that was performed daily during hospitalisation (the maximum amount of effusion during the observation period was taken as the control point), as well as up to one month after discharge from hospital.Results. The study groups did not differ regarding parameters such as time of artificial circulation (p = 0.39), time of myocardial ischaemia (p = 0.42), length of intensive care unit stay (p = 0.79) and length of hospitalisation (p = 0.21). Evaluation of pericardial effusion of varying severity during hospital follow-up revealed its presence in 15 (37.5%) patients in the PPt group and in 54 (90%) in the control group (p = 0.0001). Early postoperative cardiac tamponade developed in 4 (6.7%) patients in the control group, but was not observed in the PPt group (p = 0.09). At the same time, 5 (8.3%) patients without pericardiotomy required pericardiocentesis; however, this procedure was not performed in the PPt group (p = 0.06). Additionally, we did not find a statistically significant difference between the groups in relation to the frequency of puncture of the left pleural cavity (37.5% in the PPt group versus 43.3% in the control group, p = 0.56). According to the results of control echocardiography after one month, effusion of varying severity was found in 21 (35%) patients in the control group versus 1 (2.5%) in the PPt group (p = 0.0001).Conclusion. Posterior pericardiotomy is an affordable, applicable, safe and effective method for preventing postoperative pericardial effusion and cardiac tamponade after thoracic aortic surgery. This manipulation did not significantly affect the length of hospitalisation or the incidence of postoperative atrial fibrillation in this cohort of patients. Posterior pericardiotomy is not associated with a more frequent need for puncture of the left pleural cavity. Received 13 October 2020. Revised 10 December 2020. Accepted 11 December 2020. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest.

Comparison of posterior pleural pericardial window and pericardiocentesis in patients with cardiac tamponade

Objective: In our study, we aimed to compare the results of patients who underwent pericardiocentesis and posterior pleura-pericardial window in the treatment of cardiac tamponade. Materials and Methods: The results of all patients presenting to our hospitals with cardiac tamponade and who underwent pericardiocentesis and/or posterior pleural pericardial window (PPPW) between January 2010 and May 2021 were compared and analyzed in a retrospective review. They were divided into Group A comprising 37 patients who underwent pericardiocentesis, and Group B comprising 37 patients who underwent PPPW. Results: The mean age was 62.8 ± 7.6 years, with 54.1% males in Group A compared to 59.5 ± 12.3 years and 62.2% males in Group B. The most common etiology in Groups A and B was idiopathic in 24.3% and 16.2%, respectively. Atrial fibrillation occurred in 32.4% versus 10.8% in Groups A and B, respectively (P < 0.02), and recurrent cardiac tamponade in 24.3% versus 5.4% in Groups A and B, respectively (P < 0.02). The 30 days' mortality was 5.4% versus 10.8% in Groups A and B, respectively (P < 0.39). Conclusions: Pericardiocentesis is a safe and effective treatment for cardiac tamponade in select cases; however, PPPW was associated with a lower incidence of postoperative atrial fibrillation and recurrent cardiac tamponade at 6 and 12 months' follow-up, respectively. PPPW appears a more effective treatment option, especially in recurrent pericardial effusion.

Gender Differences in Outcomes After Implantation of Left Ventricular Assist Devices

Left ventricular assist device (LVAD) implantation has historically been underutilized in women compared with men. It was hypothesized that the introduction of continuous-flow LVADs would lead to more LVAD implantations in women and possibly narrow the gender gap. Patients who underwent LVAD implantation between 2009 and 2014 were identified using the national inpatient sample. A total of 3511 patients (17,251 when weighted) underwent LVAD implantation in the United States between 2009 and 2014. Mean age was 56 years and there were 817 women in the study sample (23.32%). LVAD implantations in women doubled from 2009 to 2014, but men continued to receive LVAD 3 times more than women. Inpatient mortality after LVAD placement was similar between men and women (13.42% women vs 12.85% men; odds ratio, 1.05; P= .16). Most common complications after LVAD implantation in both genders included acute kidney injury, bleeding requiring blood transfusion, and postoperative sepsis. There were no gender-specific differences in the incidence of periprocedural complications, including postoperative cardiac tamponade, postoperative thromboembolism, or sepsis. In addition, no significant difference was found in length of stay and median hospitalization cost. The use of extracorporeal membrane oxygenation did not differ between men and women. Subgroup analysis in patients older than 65 years of age showed higher in-hospital mortality but no differences between genders. The number of women undergoing LVAD implantation has increased with the introduction of continuous-flow LVADs, but a gender gap still exists. Most major in-hospital outcomes after LVAD implantation are similar between genders.

Incidence, Predictors, and Clinical Outcomes of Postoperative Cardiac Tamponade in Patients Undergoing Heart Valve Surgery.

This study aimed to investigate the incidence, predictors, and clinical outcomes of cardiac tamponade after heart valve surgery. A total of 556 patients who underwent heart valve surgery in a single tertiary center between January 2010 and March 2012 were studied. All patients underwent transthoracic echocardiography (TTE) about 5 days after surgery and TTE was repeated regularly. Patients with suspected acute pericardial hemorrhage were excluded. Cardiac tamponade occurred in twenty-four (4.3%) patients and all underwent surgical or percutaneous pericardial drainage. The median time of pericardial drainage after surgery was 17 (interquartile range, IQR, 13–30) days. Infective endocarditis, mechanical valve replacement of aortic or mitral valve, and any amount of pericardial effusion (PE) on the first postoperative TTE were related to the occurrence of cardiac tamponade (all p<0.05). After multivariate adjustment, occurrence of cardiac tamponade was associated with any amount of PE on the first postoperative TTE (hazard ratio, HR, 14.00, p<0.001) and mechanical valve replacement (HR 2.69, p = 0.025). The mean hospital days in patients with cardiac tamponade was higher than those without (34.9 vs. 13.5, p = 0.031). After pericardial drainage, there was no echocardiographic recurrence of significant PE during a median of 34.8 (IQR 14.9–43.7) months after surgery. Cardiac tamponade after heart valve surgery is not uncommon. Patients with any amount of PE at the first postoperative TTE or mechanical valve replacement should receive higher attention with regard to the occurrence of cardiac tamponade. Although it prolongs hospital stay, cardiac tamponade exhibits a benign clinical course without recurrence after timely intervention.

Single cusp replacement in patients with ventricular septal defect and aortic insufficiency.

The aim of this study was to analyze the mid- and long-term outcome of single cusp replacement in patients with ventricular septal defect and aortic insufficiency. From September 2005 through March 2014, 172 patients underwent single cusp replacement and ventricular septal defect (VSD) closure. The median age was 19.5 years (range, 9 months to 67 years). Additional techniques were used to repair associated anomalies including sinus of Valsalva aneurysm, patent ductus arteriosus, patent foramen ovale, subaortic membrane, and intramural coronary artery. One patient with large left ventricle (preoperative end-diastolic diameter: 9.8 cm) died after the procedure from incurable heart failure. Four patients required a second pump run for residual aortic insufficiency (AI) (two patients, 1.16%) and residual VSD (two patients, 1.16%). Four patients required re-exploration for postoperative bleeding or cardiac tamponade. Mean follow-up was 53.27 ± 25.37 months (median, 56.5 months; range, 3 to 104 months). Redo aortic valve surgery was performed in three patients. Three patients had moderate-severe AI during the following period without reoperation. There was no post-operative endocarditis. Single cusp replacement can be safely used in patients with VSD-AI.

Levosimendan increases bleeding risk after heart valve surgery: a retrospective analysis of a randomized trial.

To investigate whether levosimendan, an inotrope with cardioprotective properties, increases postoperative bleeding after cardiac surgery. Retrospective analysis of a randomized, prospective clinical study. Post-anesthesia care unit (PACU) and surgical ward in a university hospital. Two hundred heart valve surgery patients. The patients were randomized to receive either a 24-hour intravenous infusion of levosimendan or placebo. Infusion was administered as a 24 µg/kg bolus over 30 minutes and then continued at a dose of 0.2 µg/kg/min. Postoperative bleeding was approximately 31% greater in the levosimendan group (1050 mL) compared to the placebo group (880 mL, p = 0.008). Serious bleeding exceeding 1000 mL was more common in the levosimendan group than the placebo group (51 v 38 patients, p = 0.044, risk ratio (RR) 1.37, 95% CI 1.00-1.87). However, the risk of reoperation for bleeding did not increase if patients received levosimendan (RR 1.52, 95% CI 0.77-2.97, p = 0.309). This result did not change after excluding patients who received clopidogrel preoperatively (RR 2.13, 95% CI 0.98-4.65, p = 0.145). The groups did not differ regarding transfused blood products. Eight patients, including seven from the levosimendan group, had delayed (diagnosed>48 hours after the surgery) cardiac tamponade and underwent re-exploration (7 v 1, p = 0.031). Levosimendan increased the risk of postoperative bleeding after cardiac valve surgery. In addition, the risk of postoperative cardiac tamponade was increased in patients who received levosimendan compared to placebo.

Damage control surgery in blunt cardiac injury

Abstract Background: Blunt cardiac injury (BCI) is a rare, but life threatening injury. The treatment of BCI is surgical repair. However, in a BCI patient with hypothermia, acidosis, and coagulopathy, an attempt to control the bleeding completely by surgery alone may not be successful. Damage control principles should be used in this situation. Objective: To study a BCI patient who underwent a successful operation using damage control principles. Methods: We reviewed and analyzed the patient’s chart, operative notes and follow up visit records. Review of the literature regarding the issue was also conducted. Results: We report the case of a patient with BCI who developed hypothermia and coagulopathy during surgery. Abbreviated surgical repair was performed with a right pleuropericardial window created to avoid blood accumulation in the pericardial sac. Subsequent aggressive resuscitation was performed in the intensive care unit. We accepted ongoing bleeding through the right chest tubes while correction of hypothermia and coagulopathy was undertaken. The bleeding was gradually stopped once the patient’s physiology was restored. Although the patient developed a retained right hemothorax requiring subsequent video-assisted thoracoscopic surgery on the third postoperative week, he recovered uneventfully and was discharged on postoperative day 36. Conclusion: In patients with BCI who develop coagulopathy during surgery, terminating the operation quickly and creating a pleuropericardial window is a possible bailout solution because this can prevent postoperative cardiac tamponade without leaving the chest open. Continue bleeding from the chest tubes is acceptable provided that adequate resuscitation to correct coagulopathy is underway.

Delayed post-operative cardiac tamponade manifesting as cardiogenic shock

We describe the case of a 32-year-old woman with a history of cardiac surgery two weeks previously who presented with an upper gastrointestinal bleed. She also had symptoms of syncope and abdominal pain, as well as elevated liver enzymes. She had cool, clammy extremities, bilateral lower extremity edema, and oliguria. An echocardiogram was obtained, which revealed a large posterior pericardial effusion with evidence of tamponade physiology, and an emergent pericardiocentesis was performed with insertion of a drainage catheter, which drained bloody fluid, with subsequent hemodynamic improvement.<Learning objective: Cardiac tamponade symptomatology may vary tremendously from patient to patient, and therefore requires a high clinical suspicion in those presenting with evidence of cardiogenic shock. Understanding signs, symptoms, and physiology of cardiac tamponade is essential for diagnosis of delayed post-operative cardiac tamponade, occurring >7 days after open-heart surgery, a challenging diagnosis given its vague symptoms and signs not classically associated with the condition.>

Misdiagnosis by transoesophageal echo of post-operative cardiac thrombus and tamponade due to Surgicel® Fibrillar

A 54-year-old man who underwent orthotopic heart transplant developed a progressive drop in his cardiac indices, an elevated central venous pressure, and hypotension requiring inotropic support. A transoesophageal echocardiogram (TEE) was performed, demonstrating an echogenic mass measuring 11 × 8 cm located posterior to the heart adjacent to both atria ( Panels A – C , asterisk) without signs of …

Salvage use of activated recombinant factor VII in the management of refractory bleeding following cardiac surgery

Background:Refractory post cardiopulmonary bypass (CPB) bleeding continues to cause concern for cardiac surgeons and intensivists. Massive postoperative hemorrhage following CPB is multifactorial and not fully understood, and it is also associated with increased mortality and morbidity. Activated recombinant factor VII (rFVIIa) has emerged as possible salvage medication in refractory post cardiac surgical bleeding. This observational study sought to identify the pattern of use of rFVIIa in cardiac surgery, its effectiveness, and risk.Methods:This study involved a retrospective case review of medical records of ten patients undergoing a variety of cardiac surgery procedures and who developed life-threatening bleeding during surgery or after surgery despite conventional medical therapy, including transfusion of blood and blood products, and received rFVIIa at a regional center between August 2007 and April 2009.Results:All ten patients received two consecutive doses of rFVIIa (average dose 65 μg/kg) at a 2-hour interval. Eight patients were re-explored due to massive postoperative bleeding or cardiac tamponade before receiving rFVIIa. Surgical sources of bleeding were not identified in any cases. A second re-exploration was carried out in two cases. Two patients (20%) died in ITU from problems not related to bleeding and thromboembolism. Blood loss was significantly reduced after administration of rFVIIa. Blood loss 6 hours prior to treatment was 1758.5 ± 163.9 mL and blood loss in the 6-hour period post treatment was 405.6 ± 50.5 mL (P < 0.05). Blood and blood products used in the 6-hour period before and after administration of rFVIIa were 19.6 ± 1.5U and 4.4 ± 0.6U, respectively (P < 0.05). No adverse reactions or thrombotic complications related to rFVIIa were noted.Conclusion:In our limited study, use of rFVIIa in refractory post surgical bleeding was significantly reduced blood loss and use of blood and blood products. We concluded that rFVIIa can be used satisfactorily and safely as a rescue therapy in the management of post cardiac surgical bleeding.

Management of Cardiac Tamponade After Cardiac Surgery

ACUTE POSTOPERATIVE CARDIAC TAMPONADE (defined as up to 7 days post-surgery) 1 Tsang T.S. Barnes M.E. Hayes S.N. et al. Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979-1998. Chest. 1999; 116: 322-331 Crossref PubMed Scopus (136) Google Scholar is an uncommon entity that requires prompt diagnosis and diligent management to avoid circulatory collapse and cardiorespiratory arrest. Anesthetic management for surgical pericardial drainage of an effusion causing cardiac tamponade in the postoperative period after cardiac surgery is a challenge for the anesthesiologist, considering the unstable hemodynamic situation resulting from abnormal ventricular filling and the subsequent reductions in systolic volume, cardiac output, and systemic blood pressure. Such a procedure requires extensive pathophysiologic knowledge and careful hemodynamic control. After cardiac surgery, two different variants of cardiac tamponade may occur, low-pressure tamponade and regional cardiac tamponade, when any cardiac zone is compressed by loculated effusions. When these entities is suspected, the diagnosis must be prompt. The European Society of Cardiology published its Guidelines on the Diagnosis and Management of Pericardial Diseases in 2004. 2 Maisch B. Seferovic P.M. Ristic A.D. et al. Guidelines on the diagnosis and management of pericardial diseases executive summary: The Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2004; 25: 587-610 Crossref PubMed Scopus (1025) Google Scholar However, the recent literature shows a lack of publications reviewing hemodynamic and anesthetic management of patients with cardiac tamponade after cardiac surgery. This article provides an updated synopsis of the pathophysiology, diagnosis (including key clinical and echocardiographic criteria), and perioperative anesthetic management of cardiac tamponade after cardiac surgery. ErratumJournal of Cardiothoracic and Vascular AnesthesiaVol. 26Issue 4PreviewIn the article by Carmona et al from the April 2012 issue (vol 26, no 2, pages 302-311), Figure 1 was republished in modified form but did not note the original source. Full-Text PDF

Rotational pericardial flap: An alternative tension-free technique for pericardial closure

Closing the pericardium in patients with preserved ventricular function has been proposed as a protective measure attempting to minimize the hazards of injuring the myocardium, coronary grafts, and great vessels at the time of reoperation. 1 Despite its own set of advantages, in view of the increasing number of cardiac reoperations, classical pericardial closure has not gained increasing acceptance, mainly because of concerns over its attendant adverse hemodynamic effects. In the interim, using alternative techniques deemed as tension-free pericardial closure or pericardial substitutes has been advocated to benefit patients with safer resternotomy while minimizing the adverse effects on immediate postoperative hemodynamics. Following this line of reasoning, we report an alterna tive technique for tension-free pericardial closure that results in layering the right ventricular free wall and infundibulum by means of a rotational pericardial flap while leaving the great vessels unlayered, thereby minimizing the likelihood of compressive effects on the great vessels and top-end anastomosis.

Left Atrial Appendage Collapse as a Sole Feature of Cardiac Tamponade After Cardiac Surgery: A Case Report

We report on a postoperative patient with cardiac tamponade caused by posteriorly localized pericardial effusion. In this case, transthoracic echocardiography only suggested mild left atrial compression. However, transesophageal echocardiography demonstrated significant collapse of the left atrial appendage that completely disappeared after pericardial drainage. The left atrial appendage collapse should be a valuable diagnostic sign in this setting. Transesophageal echocardiography would surely be valuable in diagnosing postoperative cardiac tamponade as a result of localized effusion when clinical symptoms and transthoracic echocardiographic findings are atypical.

Surgical technique and complications during laparoscopic repair of diaphragmatic hernias

Diaphragmatic hernias can present as retrocostoxiphoid hernias (RCXH) or diaphragmatic dome hernias. The RCXH include the Larrey hernia (LH), the Morgagni hernia (MH), and the Larrey-Morgagni hernia (LMH). These congenital hernias are usually asymptomatic, and the diagnosis is simplified by two exams: chest X-ray, and thoraco-abdominal computed tomography (CT) scan. The potential risk in this condition is small-bowel incarceration in the hernia defect and subsequent obstruction. We report two cases of LH and one case of LMH treated by laparoscopy between February 2004 and October 2005, with a review of the surgical techniques. Two different laparoscopic techniques were used: the tension-free technique, and resection of the hernia sac with closure of the defect and reinforcement by prosthesis. One patient presented a postoperative cardiac tamponade due to a clip-induced bleeding of an epicardial artery at the inferior surface of the heart. Treatment by laparoscopy is feasible, but a consensus regarding the best laparoscopic repair is needed.