Prolonged Ventilation Time Research Articles

The use of spirometry testing prior to cardiac surgery may impact the Society of Thoracic Surgeons risk prediction score: A prospective study in a cohort of patients at high risk for chronic lung disease

Chronic lung disease is a significant comorbidity in patients undergoing cardiac surgery. Chronic lung disease is currently being classified and reported to the Society of Thoracic Surgeons database by using either clinical interview or spirometric testing. We sought to compare the chronic lung disease classification captured by the 2 methods. We performed a prospectively designed study in which patients presenting for cardiac surgery, excluding emergent patients, were screened for a history of asthma, a history of 10 or more pack-years of smoking, a persistent cough, and the use of oxygen. Each selected patient underwent spirometry. The presence and severity of chronic lung disease was coded per Society of Thoracic Surgeons guidelines by using the 2 methods of clinical report and spirometric results. The chronic lung disease classifications were compared, and differences were determined by using concordance and discordance rates. The results were then used to construct Society of Thoracic Surgeons-predicted risk models. The discordant rate was 39.1%, with underestimation of the severity of chronic lung disease in 94% of misclassified patients. This affected the Society of Thoracic Surgeons-predicted risk models for prolonged ventilation, morbidity/mortality, and mortality by increasing the predicted risk when spirometry was used for morbidity/mortality by an average of 1.5 +/- 1.2 percentage points (P < .001) and prolonged ventilation time by an average of 1.3 +/- 1.4 percentage points (P < .001). The use of patient history for symptoms, medication, and/or oxygen use as the only method to determine chronic lung disease for this subgroup of patients led to underreporting of chronic lung disease and underestimation of the risk for adverse outcomes. Therefore data submission to the Society of Thoracic Surgeons database should be designed to capture and correct for potential bias in the definition of chronic lung disease because the rate of spirometry in different centers in defining chronic lung disease is not regulated.

Additional spirometry criteria predict postoperative complications after coronary artery bypass grafting (CABG) independently of concomitant chronic obstructive pulmonary disease. When is off‑pump CABG more beneficial?

Concomitant chronic obstructive pulmonary disease (COPD) is associated with an increased rate of post-coronary artery bypass grafting (CABG) complications. The ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) <70%, proposed by the Global Initiative for Chronic Obstructive Lung Disease as a criterion for the diagnosis of COPD, is criticized for not considering physiological, age-related changes in lung function. The aim of the study was to evaluate which of the additional spirometric parameters, adjusted for age and the distribution of values in the population, represent the best predictors of post-CABG complications and to identify patients who are more likely to benefit from off-pump cardiac bypass (OPCAB) than from CABG. In the retrospective cohort study, data from a total of 3617 CABG or OPCAB patients were recorded. Patients with COPD, diagnosed prior to admission, were classified according to the spirometry results: group 1 with FEV1/FVC <70%, group 2 with FEV1/FVC below the mean normal value adjusted to age, group 3 with FEV1/FVC below the lower limit of normal (LLN), group 4 with FEV1 <LLN. The control group comprised subjects with no history of COPD. The occurrence of post-CABG complications was analyzed using the chi2 and Mann-Whitney U tests. FEV1 below LLN predicted a higher incidence of reoperation, readmission to intensive care unit (ICU), sternal wound infection, pulmonary complications, and pulmonary edema after surgery (p <0.05). CABG patients with FEV1 below LLN stayed in the ICU significantly longer than OPCAB patients, and tended to require prolonged mechanical ventilation and more time from operation to discharge. FEV1 <LLN is the best prognostic marker for post-CABG complications independently of concomitant COPD. Patients with FEV1 <LLN have better outcomes after OPCAB compared with those post-CABG.

Reduction of Early Postoperative Morbidity in Cardiac Surgery Patients Treated With Continuous Veno–Venous Hemofiltration During Cardiopulmonary Bypass

Cardiac surgery with cardiopulmonary bypass is associated with a systemic inflammatory response syndrome. The major clinical features of this include a reduction of pulmonary compliance and increased extracellular fluids, with increased pulmonary shunt fraction similar to acute respiratory distress syndrome, thus resulting in prolonged mechanical ventilation time (VAM) and intensive care unit length of stay (ICU STAY). We evaluated the feasibility of an intraoperatory cardiopulmonary bypass (CPB) circuit connected with a monitor for continuous veno-venous hemofiltration (CVVH) to ameliorate pulmonary function after open heart surgery reducing VAM and ICU STAY. Forty patients undergoing elective coronary artery bypass grafting were randomized at the time of surgery into a control group (20 patients who received standard cardiopulmonary bypass) and a study group (20 patients who received CVVH during cardiopulmonary bypass). The analysis of postoperative variables showed a significative reduction of VAM in treated group (CVVH group mean 3.55 h +/- 0.85, control group 5.8 h +/- 0.94, P < 0.001) and ICU STAY (CVVH group mean 29.5 h +/- 6.7, control group 40.5 h +/- 6.67, P < 0.001). In our experience, the use of intraoperatory CVVH during cardiopulmonary bypass is associated with lower early postoperative morbidity.

Importance of early dialysis for acute renal failure after an open‐heart surgery

Coronary artery disease is a major cause of death in patients with a renal dysfunction. Among the patients who undergo coronary artery bypass grafting, renal dysfunction is known to be a major predictor of in-hospital and out-of-hospital mortality. From 2004 to 2007, we performed elective open-heart surgeries on 2380 patients in whom there was no primary renal failure. Of those patients, only 185 in whom acute renal failure (ARF) was developed were included in the study. The patients were divided into 2 groups: a late dialysis group (n=90) and an early dialysis group (n=95). The mean age of the patients was 62.3+/-6.4 in the late dialysis group and 64.5+/-5.2 in the early dialysis group. There were 32 female and 58 male patients in the late dialysis group and 36 female and 59 male patients in the early dialysis group. Acute renal failure developed only in 185 patients out of 2380 open-heart surgery patients. The overall mortality in the 2380 open-heart surgery patients was 1.97%. Mortality among the ARF patients was 5.9%. However, there was no significant difference in hospital mortality between the 2 groups. Major complications, such as postoperative pneumonia, prolonged ventilation time, arrhythmia, the number of times postoperative hemodialysis was performed, development of chronic renal failure, time spent in the intensive care unit and the period of hospitalization, sepsis, and low cardiac output, were significantly higher in the late dialysis group. There was no difference in mortality between the 2 groups. Early dialysis for open-heart surgery patients who develop ARF postoperatively does not decrease mortality. However, it decreases morbidity, the amount of time spent in intensive care, and the period of hospitalization and thus reduces patient costs.

Differences in Early Postoperative Complications in Elective and Emergency Heart Transplantation

Introduction and Objectives The immediate postoperative period is a critical phase in heart transplantation. Severe complications occur that may influence short-term and medium-term morbidity and mortality in these patients. The aim of this study was to analyze the incidence of severe complications in emergency and nonemergency transplantations. Materials and Methods We studied 152 patients who underwent heart transplantation between 2001 and 2007. Combined transplantations and retransplantations were excluded. Two groups were considered: emergency transplantations (36 patients, 24%) and elective transplantations. We compared survival and occurrence of infection, primary graft failure (PGF), renal and hepatic failure, respiratory complications, cardiac tamponade, arrhythmias, reoperation, and intensive care unit (ICU) stay. Results The emergency transplantation group had a greater number of ischemic patients, with a more prolonged cardiopulmonary bypass time, and a larger proportion of donors were women. Overall mortality in the intensive care unit was 2.6%, with no differences between groups. However, emergency procedures were significantly associated with a higher incidence of PGF, need for intraaortic balloon pump, and a more prolonged mechanical ventilation time, as well as a greater number of bacterial infections and a significantly longer ICU stay. Conclusions In our series, emergency transplantation showed no greater perioperative mortality. We observed a greater number of severe complications, such as PGF, bacterial infection, and more prolonged mechanical ventilation time.

Bloodless Cardiac Surgery is Associated With Decreased Morbidity and Mortality

Blood transfusion with cardiac surgery accounts for 20% of transfusions in the United States. The effect of perioperative transfusion on cardiac surgery outcomes is unknown. We hypothesized that cardiac surgery with perioperative blood transfusion was associated with worse outcomes. A prospectively maintained (Society of Thoracic Surgeons) institutional database was analyzed from 2000 to 2005. All patients undergoing coronary artery bypass and/or valve operations were evaluated for the association of preoperative and intraoperative risk factors with blood transfusion. The association of transfusion with postoperative complications and mortality was evaluated. During the study period, 2691 patients met inclusion criteria. Sixty-four percent received transfusions. Preoperative risk factors associated with transfusion (p < 0.05) were lung disease, elevated creatinine, peripheral vascular disease, and previous cardiac interventions. Patients requiring transfusion were older (mean 65.2 vs. 61.2 years, p < 0.001). Transfusion was associated with longer cross-clamp (median 78 vs. 88 minutes, p < 0.001) and perfusion times (median 114 vs. 128 minutes, p < 0.001). Perioperative blood transfusion was associated with increased postoperative complications (53.5% vs. 30.5%, p < 0.001). Significant transfusion-associated complications were renal failure, prolonged ventilation time, pneumonia, cardiac arrest, gastrointestinal complications, atrial fibrillation, stroke, myocardial infarction, and bleeding requiring reoperation. Blood transfusion was associated with an increased operative mortality (3.4% vs. 1.7%, p = 0.005) and length of stay after surgery (median 6 vs. 5 days p < 0.001). Identification and management of risk factors associated with transfusion may reduce the transfusion requirement, minimize perioperative complications and improve outcomes. Bloodless cardiac surgery is associated with a decreased morbidity and mortality.

Being an elderly woman: is it a risk factor for morbidity after coronary artery bypass surgery?

Despite the refinements in surgical techniques and postoperative care, elderly women still have a higher prevalence of postoperative morbidity. The outcomes of 112 elderly women (>80 years) who underwent an elective CABG procedure were compared with those of males operated during the same time interval (n, 164). Median age of female and male patients were 82 and 83 years, respectively. Mean number of grafts did not differ significantly (3.7+/-0.8 vs 3.9+/-0.3, p=0.4) between groups. Overall early operative mortality rate was 8.6% (24 of 276 patients); 8.9% (10 of 112 patients) for female and 8.5% (14 of 164 patients) for male patients (p=0.1). Postoperative complications including prolonged ventilation time (13.4% in females vs 8.5% in male, p<0.01), atrial fibrillation (40% in females vs 33% in males, p=0.01), sternal reclosure (8% in females vs 4.2% in males, p=0.01), pneumonia (5.3% in females vs 3% in males, p=0.03), leg wound infection (11.7% in females vs 2.4% in males, p<0.001), renal dysfunction (10.7% in females vs 7.3% in young patients, p=0.02) have been found to be significantly higher in elderly women. Mean intensive care unit (3.2+/-1.1 days in females vs 1.6+/-0.4 in males, p=0.03), and hospital stays (13.6+/-2.1 days in females vs 9.1+/-1.2 in males, p=0.02) were also longer in female patients. Five-year survivals including all deaths for female and male patients were 57% and 62%, respectively. In elderly women, revascularization procedures can be done with acceptable mortality rates; but these patients are still associated with a higher prevalence of postoperative morbidity when compared with the male counterparts. Therefore, these patients have to be very carefully evaluated preoperatively and their postoperative care should be more comprehensive to reduce the incidence of postoperative complications.

Advanced glycation endproducts: A biomarker for age as an outcome predictor after cardiac surgery?

Objective. A decline in the function of all organs can be detected during ageing. Although the trend appears to be stable, deviation within the elderly population is much greater in comparison to young controls. The aim of the study was to identify a marker of senescence which correlates to heart function. Advanced glycation endproducts (AGEs) accumulate with age and are associated with degenerative diseases. Methods. Carboxymethyllysine (CML) concentrations in the pericardial fluid (as a measure of AGEs) were analysed with ELISA technique in 75 patients undergoing cardiac surgery and correlated with clinical parameters and outcome of these patients. Results. CML content of pericardial fluid increases significantly with age. AGEs show an inverse correlation to left ventricular ejection fraction. High CML levels correlate with poor outcome of patients as shown by adverse cardiac events, prolonged ventilation time and prolonged stay within the Intensive Care Unit. Within all parameters, AGE concentration of the pericardial fluid fits better with the outcome of the patients in comparison to age alone. Interestingly, medical treatment with nitrates correlates with increased CML content. Conclusion. AGEs, in addition to being a marker of senescence, appear to represent a prognostic factor in cardiac surgery, which can be used as a predictor of patient outcome.

Incidence and precipitating factors of delirium after coronary artery bypass grafting

Objective. To analyze large contemporary patient population, undergoing on-pump coronary artery bypass grafting at our institution, and identify the prevalence and precipitating factors of delirium development. Design. Baseline demographics, operative data and postoperative outcomes of 1367 consecutive patients were recorded prospectively and analysed using multivariate logistic regression analysis, to determine independent predictors of postoperative delirium development. Results. Delirium was detected in 42 (3.07%) patients. Eight factors: age more than 65 years, peripheral vascular disease, Euroscore≥5, preoperative IABP support, postoperative blood product usage and postoperative low cardiac output syndrome were independently predicting delirium development after coronary artery bypass procedures. Postoperative delirium was associated with significantly higher mortality rate (16.6% vs. 3.9%, p=0.013), prolonged mechanical ventilation time (9.2±3.1 vs. 5.05±7.6, p=0.04) and increased length of intensive care unit stay (6.8±4.9 vs. 2.0±2.7 days, p=0.001). Conclusions. Delirium is a dangerous complication, prolonging intensive care unit stay and postoperative mortality. Factors associated with delirium development are advanced age, peripheral vascular disease, diminished cardiac function and blood product usage.

Technical challenges in totally endoscopic robotic coronary artery bypass grafting

Robotic technology is a prerequisite for performance of totally endoscopic coronary artery bypass grafting. During the implementation phase of totally endoscopic coronary artery bypass, surgeon-related technical difficulties might be encountered. It was the aim of this study to assess the incidence of these challenges, to find risk factors, and to describe clinical results associated with technical errors. From October 2001 through October 2004, 40 patients received robotically assisted totally endoscopic left internal thoracic artery grafts to the left anterior descending coronary artery system with the da Vinci telemanipulation device. All patients underwent remote access cardiopulmonary bypass perfusion through groin access, and all anastomoses were performed on the arrested heart. Undesirable technical events of various grades occurred in 20 (50%) of 40 patients: bleeding from a port hole in 3 (8%), left internal thoracic artery damage in 3 (8%), epicardial lesion in 3 (8%), remote access perfusion problems in 9 (23%), bleeding from the anastomosis in 4 (10%), and anastomotic stenosis in 2 (5%). There was no hospital mortality. The following differences were noted between patients without technical difficulties (group 1) and those in whom problems occurred (group 2): total operative time of 314 minutes (260-540 minutes) versus 418 minutes (270-690 minutes; P = .007), ventilation time of 6 hours (0-26 hours) versus 14 hours (0-278 hours; P = .004), intensive care unit stay of 20 hours (11-70 hours) versus 44 hours (16-336 hours; P=.183), hospital stay of 7 days (4-13 days) versus 8 days (5-21 days; P = .038), and cumulative freedom from angina at 36 months of 93% versus 100% (P = .317). We conclude that technical difficulties during totally endoscopic coronary artery bypass grafting translate into markedly increased operative time, moderately prolonged postoperative ventilation time, and slightly increased hospital stay. Short-term survival and freedom from angina, however, do not seem to be compromised.

Determinants and Prognosis of Myocardial Damage After Coronary Artery Bypass Grafting

Myocardial infarction remains a devastating complication after coronary revascularization. Although electrocardiography (ECG) and echocardiography suggest transmural infarction, myocardial damage and the quality of myocardial protection are not recognized unless troponin I (TnI) is assessed. Determinants and prognosis of TnI elevation after coronary artery bypass grafting (CABG) were evaluated. Data of 776 consecutive patients undergoing CABG between January 2002 and January 2004 were prospectively exposed to univariate and multivariate analysis. We evaluated the prognosis of patients with all the ECG, echocardiographic, and biochemical criteria for acute myocardial infarction and that of patients with only TnI elevation. Twelve-month follow-up survival and freedom from cardiac events (FCE) were accomplished. Troponin I greater than 3.1 mug/L at 12 hours was detected in 6.9% of the population, and correlated with lower in-hospital (p < 0.001) and follow-up survival (p = 0.00001), and lower FCE (p = 0.0009). Twenty-one (38.8%) of these fulfilled ECG-echocardiographic criteria (p = 0.05), demonstrating higher TnI values at 12 (p = 0.001), 24 (p = 0.01), 48 (p = 0.01), and 72 (p = 0.04) hours, prolonged ventilation time (p = 0.001), higher in hospital mortality (p = 0.003), lower follow-up survival (p = 0.023), and lower FCE (p = 0.0084). A EuroSCORE greater than 6, ongoing unstable angina, aortic cross-clamp time greater than 90 minutes, cardiopulmonary bypass time greater than 180 minutes, incomplete revascularization, and intraoperative intraaortic balloon pump were independent predictors of myocardial damage (MD) at multivariate analysis. Combined antegrade and retrograde cardioplegia and postoperative enoximone infusion were associated with a lower TnI elevation. Troponin I greater than 3.1 mug/L at 12 hours defines perioperative MD. Associated ECG-echocardiographic criteria indicate acute myocardial infarction and anticipate a worse outcome. Identification of predictors for MD is important to develop preventative strategies, as antegrade plus retrograde cardioplegia and enoximone infusion.

Routine intracoronary shunting in multivessel off-pump coronary artery bypass: a retrospective review of in-hospital outcomes in 550 consecutive cases.

Since 1999 our institution has adopted offpump coronary artery bypass grafting (OPCABG) for treating the majority of our patients. In the year 2001, 96% of our isolated coronary bypass procedures were performed on the beating heart. Routine use of intracoronary shunts in OPCABG has been a controversial topic. We use routine intracoronary shunting in all cases to maintain distal perfusion and to help achieve hemostasis. We reviewed the first 550 OPCABG procedures performed at our institution (July 1998-December 2001) by 2 surgeons currently performing >95% of all coronary bypasses off-pump. All cases were completed with routine intracoronary shunting using Flo-Coil (Guidant, Santa Clara, CA, USA) or Flo-Thru (Bio-Vascular, St Paul, MN, USA) shunts. The mean number of grafts was 3.7. (range, 1-8). In-hospital outcomes in this series of patients were compared to outcomes in 485 patients operated on by the same 2 surgeons using traditional cardiopulmonary bypass (CPB) and aortic cross-clamping prior to adopting routine OPCABG. Statistical significance was calculated using Pearson chisquare analysis and reported for P values of <.05. The rates of occurrence of postoperative cardiovascular accident, atrial fibrillation, prolonged ventilator time, renal failure, and blood product use and the length of postoperative stay were significantly less in the off-pump group (P <.05). Predicted risk of mortality, observed mortality, and perioperative myocardial infarction rates were not significantly different in the 2 groups (P <.05). The conversion rate was 3.1%. We conclude that routine intracoronary shunting in OPCABG is a safe technique that is associated with good myocardial preservation and allows for total revascularization with a low rate of conversion to CPB.

Postoperative antithrombin levels and outcome in cardiac operations

During cardiac operations with cardiopulmonary bypass surgery, antithrombin is consumed and low levels of antithrombin activity are commonly observed at admission to the intensive care unit (ICU). This study investigates the association between antithrombin activity at admission to the ICU (ICU-antithrombin activity) and various outcome variables. The authors conducted a prospective, observational cohort study. The study was conducted at a university hospital. The study consisted of 647 consecutive patients who had undergone cardiac surgery with cardiopulmonary bypass. ICU-antithrombin activity significantly (p < .001) decreased with respect to preoperative values. As seen with univariate analysis, low levels of ICU-antithrombin activity were significantly associated with higher blood loss, prolonged mechanical ventilation time and ICU stay, a higher incidence of allogeneic blood products use, surgical reexploration, low cardiac output syndrome, adverse neurologic events, thromboembolic events, renal dysfunction, and hospital mortality. When corrected for the other explanatory variables, low levels of ICU-antithrombin activity remained independently associated with a prolonged ICU stay (p = .003) and with a higher incidence of surgical reexploration (p = .023), adverse neurologic events (p = .001), and thromboembolic events (p = .036). An ICU-antithrombin activity value of <58% was found to be predictive of prolonged ICU stay, with a sensitivity of 67% and a specificity of 83%. Low levels of ICU-antithrombin activity are associated with a poor outcome in cardiac surgery; ICU-antithrombin activity is predictive of prolonged ICU stay.

Preoperative State of Mind Among Patients Undergoing CABG

This study was undertaken to determine if a pessimistic self-assessment prior to an elective coronary artery bypass graft (CABG) was predictive of postoperative complications and increased length of stay (LOS). Subjects (n = 565), aged 65 and older and undergoing elective CABG, were stratified into 2 groups (optimistic, pessimistic) based on their mental health subscale scores prior to surgery. After adjusting for age, gender, and severity of disease, the average LOS for pessimistic patients was 1.3 days longer than for optimistic patients. Despite adjustment for previous CABG, renal failure, peripheral vascular disease, and gender, pessimism was associated with an increased risk of prolonged ventilation time and permanent stroke. Negative state of mind prior to a major cardiovascular intervention may be predictive of increased LOS, permanent stroke, and prolonged ventilation time.

Albumin‐Coated Tympanostomy Tubes: Prospective, Double‐Blind Clinical Study

Coating an implant with albumin prevents adhesion of proteins, bacteria, and platelets and thus may lead to its improved and prolonged function. Previously, we have demonstrated the inhibition of binding of fibronectin, one of the most adhesive glycoproteins, on human serum albumin (HSA)-coated tympanostomy tubes and the durability of this binding inhibition in a 8-month trial. We have also demonstrated that the HSA coating inhibits the binding of Staphylococcus aureus and Pseudomonas aeruginosa to titanium plates. This prospective study evaluated the effect of albumin coating on tympanostomy tube sequelae and on the outcome of tympanostomized patients. Double-blind, prospective, randomized clinical trial. Two otolaryngological centers in southern Finland enrolled 179 pediatric patients. Number of tube occlusions and otorrhea and tube ventilation time in the ears with HSA-coated titanium tympanostomy tubes were compared with the contralateral ear with its uncoated, otherwise identical titanium tube during a 9-month follow-up period. In HSA-coated tubes, average ventilation time was slightly longer and the number of early tube occlusions significantly less (P < .05). Moreover, in patients with perioperative bleeding, the coating prolonged average ventilation time of tympanostomy tubes significantly (P < .05). HSA coating reduces early tube occlusions by preventing adherence of blood and secretion.

Erythrocyte Transfusion and Postsurgical Morbidity in Cardiac Surgery Patients: Is It the Storage Time or the Number of Transfused Concentrates that Really Matters?

To the Editor:—We read with interest the article about the influence of erythrocyte concentrate storage time on postoperative morbidity in cardiac surgery patients published by Leal-Noval et al. in a recent issue of the Journal, 1which was accompanied by an editorial view. 2The main finding of this study was an association between storage time of packed red blood cells (PRBC) and the acquisition of postoperative nosocomial pneumonia, but not between the former and prolonged mechanical ventilation time. We would like to comment regarding two points. First, we wish to review some mechanisms by which the relationship between the number of units and pneumonia/ventilation might be connected. Second, we want to point out that the problem may not simply be the age of the transfused blood, but also the absolute numbers of units transfused.The current authors suggested that allogeneic transfusion may cause some deleterious effects that have not been recognized and which may explain the association between the number of PRBC transfusions and prolonged mechanical ventilation, but not between the duration of storage and prolonged mechanical ventilation. 1Induction of a subclinical transfusion-related acute lung injury (TRALI) could be one of those frequently underdiagnosed deleterious effects. It has been proposed that TRALI is the result of two clinical events, the first being a predisposing clinical condition (e.g. , a postoperative systemic inflammatory response syndrome) and the second being the transfusion of biologically active molecules in stored PRBC and platelets that have neutrophil priming activity. The concentration of some of these molecules (e.g. , cytokines, neutral lipids, lysophosphatidylserine) in the stored blood component increases with the product age, whereas that of other molecules (e.g. , human lymphocyte antibody class I, class II, and granulocyte antibodies) does not. To this regard, Silliman et al. 3have found that TRALI was associated with the transfusion of older blood products, especially platelets, and that patients with cardiac disease who required cardiopulmonary bypass were at particular risk to develop TRALI reactions. However, although a significant proportion of patients (135, 16.9%) received platelet transfusion, Leal-Noval et al. 1have not studied the possible association between either the number or the age of platelet concentrates and prolonged mechanical ventilation time. Despite that, because the number of PRBC transfused was significantly higher in patients with mechanical ventilation time greater than 24 h, the development of a certain degree of TRALI, in a dose-dependent manner, may result in a worsening of the pulmonary dysfunction induced by cardiopulmonary bypass with a prolonged mechanical ventilation time and, perhaps, contributes to a higher incidence of postoperative nosocomial pneumonia. 4Regarding PRBC storage time, there are several storage-dependent alterations in erythrocytes that, together with transfusion-related immunomodulation, may contribute to the increased risk of nosocomial pneumonia in the transfused patients. The decrease in the ability of erythrocytes to deform and unload oxygen in the peripheral tissues, possibly favoring the degree of visceral ischemia, have been mentioned, 1,2but other alterations may account for when erythrocytes are stored together with white blood cells. Leukocyte enzymes, including neuraminidase, are definitive contributors to the desialylation of erythrocytes during storage and to the exposure of phosphatidylserine residues in the membrane outer leaflet. 5These changes make the erythrocytes more adherent to the inflamed endothelium and convert it into a procoagulant surface, thus contributing to the alteration of microvascular blood flow. In addition, these changes are also signals of senescence and enhance erythrocyte phagocytosis by resident macrophages. 5All methods in current use for erythrocyte storage result in the maintenance of 90% or more of the in vivo recovery for about 2–3 weeks; later an increasing proportion of erythrocytes become nonviable. When old PRBC are transfused, a substantial number of cells (some 1012erythrocytes in a four-unit transfusion) must be phagocytosed, which obviously uses part of the capacity of the phagocytic mononuclear system and may compete with infection defense with possible serious consequences, such as postoperative nosocomial pneumonia. 6We agree with Leal-Noval et al. 1with regard to the need for continued research of the possible deleterious effects of old PRBC transfusion. However, in previous work, 4this group showed an increase in the incidence of postoperative nosocomial pneumonia in those patients transfused with more than 4 units. In the present work, 1patients who developed postoperative nosocomial pneumonia received more PRBC units than those who did not (8.8 ± 4.7 vs. 5.4 ± 4.7, respectively; P &lt; 0.05). Because the authors found that each transfused PRBC unit increased the risk of postoperative pneumonia by 11%, 1we believe that the implementation of a perioperative blood-saving program, including several alternatives to allogeneic erythrocyte transfusion (e.g. , preoperative treatment of anemia, aprotinin in pump-prime, perioperative autologous salvage), together with a restrictive transfusion strategy, 7–9would probably be a better option to reduce postoperative morbidity in cardiac surgery patients.

Postoperative complications among octogenarians after cardiovascular surgery

Background The octogenarian patient is often perceived as too fragile to undergo cardiothoracic surgery. Our study aimed to compare postoperative complications in patients aged less than 80 versus elderly patients (80 years or more) after surgical cardiac intervention (coronary artery bypass or valve replacement). Methods Subjects were all patients (n = 8,361) who had an open-heart procedure, either coronary artery bypass or valve implantation or replacement, at two medical centers located in northern Virginia using the same surgical group. A computerized medical record database was reviewed to determine preoperative risk factors and postoperative outcomes. Predictors of complications were identified by univariate and multivariate logistic regression. Results A total of 3,214 complications were recorded. The most prevalent complications were prolonged ventilation time in the intensive care unit, reoperation for bleeding, and pneumonia. The overall mortality rate was 2.4% (204 of 8,361). Persons aged over 80 years had nearly double the mortality rate compared with younger patients (4.1% [18 of 444] to 2.3% [186 of 7,917]). Age greater than 80 years (odds ratio = 2.65, 95% confidence interval = 2.18 to 3.22) and male gender (odds ratio = 0.62, 95% confidence interval = 0.56 to 0.69) were the best univariate predictors of a single postoperative complication. Conclusions Octogenarian patients manifested twice the risk of death from a cardiac intervention with an average 2-day longer hospital stay compared with their younger counterparts. Furthermore, octogenarians were at markedly higher risk of nonfatal postoperative complications.

Vocal cord paralysis after subtotal oesophagectomy.

Although vocal cord paralysis is a well known complication of subtotal oesophagectomy, precise data concerning origin, incidence and associated morbidity are lacking. A retrospective study was performed of 241 patients who underwent transhiatal oesophagectomy for carcinoma of the mid/distal oesophagus between 1994 and 1998. Preoperative and postoperative laryngoscopy results were available for 140 patients. There were 109 men and 31 women, of mean age 63 years. Thirty-one patients (22 per cent) with recurrent laryngeal nerve paralysis were identified, three with bilateral and 28 with unilateral dysfunction. Paralysis occurred ipsilateral to the side of the cervical incision in 22 of 28 patients. It was permanent in six patients. The associated morbidity was substantial: pulmonary complications were more common in patients with vocal cord paralysis (12 of 31 versus 26 (24 per cent) of 109), leading to significantly more reintubations, and a significantly prolonged ventilation time and stay in the intensive care unit. Although mostly transient, vocal cord paralysis is a frequent complication with significant associated morbidity. In an extended transthoracic resection (including a lymphadenectomy in the aortopulmonary window where the left recurrent laryngeal nerve is at risk) the cervical anastomosis should be made on the left side, to minimize the risk of bilateral vocal cord paralysis.

The clamshell approach for the surgical treatment of complex cardiopulmonary pathology in infants and children

The surgical approach to children with complex cardiovascular and pulmonary anomalies is still controversial. Staged operations through multiple incisions are often performed in this setting. The different applications and clinical advantages of a bilateral thoracosternotomy approach to complex cardiothoracic disease requiring surgical repair were reviewed retrospectively. Between January 1993 and June 1995, 33 patients, aged between 2 months and 17 years (mean 7.8 +/- 5.3) underwent surgical treatment of complex cardiovascular or pulmonary disease using a clamshell approach. Twenty-one patients (64%) had undergone 1-5 previous surgical procedures (mean 2.5 +/- 1.0/patient). The technique involved supine position placement, submammary incision, access to the pleural space bilaterally through the fourth intercostal space and transverse division of the sternal body. Four groups of patients were operated on via this approach: (1) patients undergoing lobar, lung or heart-lung transplantation (40%); (2) patients undergoing repair of tetralogy of Fallot/pulmonary atresia (36%); (3) patients with previously corrected miscellaneous procedures (12%), including completion of Fontan, one-stage repair of left main bronchial stenosis and atrial septal defect, one-stage repair of partial anomalous pulmonary venous connection and aortic coarctation, and repair of congenital pulmonary venous stenosis. There were two early (< 30 days) deaths, giving a perioperative mortality of 6% for the entire series. Complications included postoperative hemorrhage in 4 patients (12%), prolonged ventilation time due to mechanical failure in 4 (12%). There were no wound infections. Analysis of complications by group showed the lung transplant group to be more affected (18% of patients experienced complications). Except for 2 infants undergoing complete unifocalization and presently awaiting completion of repair of tetralogy of Fallot/pulmonary atresia, in the remaining 31 (94%) a definitive surgical treatment could be performed in one-stage. The bilateral thoracosternotomy allows optimal exposure of all intrathoracic anatomic structures making one-stage surgical repair possible in a variety of complex cardiovascular and pulmonary anomalies. Early mortality and technique-related morbidity do not differ from those reported with the conventional approaches to the different disease conditions. A wider application of the clamshell approach for the management of complex intrathoracic pathology in infants and children is advocated.

Gastrointestinal complications after cardiac surgery.

Gastrointestinal (GI) complications after cardiac surgery with cardiopulmonary bypass (CPB) are uncommon complications with significant morbidity and mortality rates. From 1988 to 1995, 36 GI complications were identified in 3158 patients who underwent cardiac surgery (1.14% incidence). The mortality rate was 13.9%. Complications included hemorrhage in the GI tract in 22, perforated ulcer in 3, acute cholecystitis in 3, pancreatitis in 2, mesenteric ischemia in 3, diverticulitis in 1 and liver failure in 2 patients. Clinical risk factors included advanced age, combined coronary artery bypass grafting (CABG)-valve operation, postoperative low cardiac output (LCO), prolonged ventilation time, re-exploration of the chest, sternal infection and a positive history of peptic ulcer. Patients with a prolonged pump time had an increased risk of GI complications (P < 0.001). Gastrointestinal complications, although of low incidence, carry a significantly high mortality, and the clinician must be alert to institute early appropriate treatment.