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<1>
Accession Number
2012261633
Authors
Ryan L. Rodseth R.N. Biccard B.M.
Institution
(Ryan, Rodseth, Biccard) Perioperative Research Unit, Department of
Anaesthetics, Nelson R Mandela School of Medicine, University of
KwaZulu-Natal, South Africa
(Rodseth, Biccard) Inkosi Albert Luthuli Central Hospital, Mayville,
United States
Title
The treatment of perioperative myocardial infarctions following noncardiac
surgery.
Source
Southern African Journal of Anaesthesia and Analgesia. 18 (2) (pp 86-93),
2012. Date of Publication: 2012.
Publisher
Medpharm Publications (Pty) Ltd (PO Box 14804, Lyttelton, Gauteng 0157,
South Africa)
Abstract
Background: Perioperative myocardial infarction (PMI) is a common
complication following noncardiac surgery, with a 30-day mortality of
10-20%. Effective therapeutic interventions are of public health
importance. Method: This is a systematic review, aimed to determine the
evidence for therapies following PMI. Results: A PubMed Central search up
to May 2011 identified 20 case series and reports (89 patients). We
extracted data on the type and timing of treatment and short-term
mortality. Short-term mortality differed significantly between
haemodynamically stable and unstable patients (0% and 32.2% respectively,
p-value = 0.015). Significantly more haemodynamically unstable patients
received acute coronary interventions (75.8% vs. 23.1%, p-value = 0.0006).
Acute coronary intervention in haemodynamically unstable patients was not
associated with improved short-term survival (p-value = 0.53). The high
proportion of symptomatic and haemodynamically unstable patients suggests
publication bias (chi² = 16.29, p-value = 0 < 0001 and
chi² = 154.41, p-value < 0.0001, respectively). Conclusion:
This systematic review highlights the paucity of evidence for PMI
management, and the need for future prospective trials. SASA.

<2>
Accession Number
2012248284
Authors
Elgebaly A.S. Sabry M.
Institution
(Elgebaly) Department of Anesthesia and SICU, Faculty of Medicine, Tanta
University, 43 IBN Elfard Street, Elgharbia, Tanta, Egypt
(Sabry) Department of Cardiothoracic Surgery, Faculty of Medicine, Tanta
University, Egypt
Title
Infusion of low-dose vasopressin improves left ventricular function during
separation from cardiopulmonary bypass: A double-blind randomized study.
Source
Annals of Cardiac Anaesthesia. 15 (2) (pp 128-133), 2012. Date of
Publication: April-June 2012.
Publisher
Medknow Publications and Media Pvt. Ltd (B9, Kanara Business Centre, off
Link Road, Ghatkopar (E), Mumbai 400 075, India)
Abstract
We aimed to investigate whether low-dose vasopressin administered to
patients undergoing coronary artery bypass grafting (CABG) surgery with
preexisting mild to moderate systolic dysfunction can produce sustained
improvement in cardiac function. This double-blind randomized study was
conducted in a hospital where a single anesthetic and surgical team
performed elective CABG. Twenty patients aged 32-61 years who underwent
elective CABG between January 2007 and December 2007 were enrolled in this
study. The patients randomly received either vasopressin 0.03 IU/min
(Group A) or normal saline (Group B) in equal volume for 60 min after
cardiopulmonary bypass (CPB). The cardiac output, cardiac index, stroke
volume index, fractional area of contraction and systemic vascular
resistance index were significantly higher in Group A than in Group B.
Adrenaline (mean dose: 0.06 mug/kgmin-1) was required in seven patients
from Group B but in none of the Group A patients on initial separation
from CPB (P< 0.05). Of the 10 patients in Group B, five required
phenylepherine to maintain the mean arterial pressure (MAP) >65 mmHg,
whereas none of the Group A patients required phenylephrine for MAP
regulation (P< 0.05). We conclude that Infusion of low-dose vasopressin
for patients with mild to moderate left ventricular systolic dysfunction
during separation from CPB is beneficial for the postoperative hemodynamic
profile, reduces the catecholamine doses required and improves left
ventricular systolic function.

<3>
Accession Number
2012248283
Authors
Mukherjee C. Koch E. Banusch J. Scholz M. Kaisers U.X. Ender J.
Institution
(Mukherjee, Koch, Banusch, Ender) Department of Anesthesiology and
Intensive Care Medicine II, Heart Center Leipzig, University of Leipzig,
Strumpelstrasse 39, 04289 Leipzig, Germany
(Scholz) Institute of Medical Informatics, Statistics and Epidemiology,
University of Leipzig, Germany
(Kaisers) Department of Anesthesiology, Intensive Care Medicine Medical
Faculty, University of Leipzig, Germany
Title
Intrathecal morphine is superior to intravenous PCA in patients undergoing
minimally invasive cardiac surgery.
Source
Annals of Cardiac Anaesthesia. 15 (2) (pp 122-127), 2012. Date of
Publication: April-June 2012.
Publisher
Medknow Publications and Media Pvt. Ltd (B9, Kanara Business Centre, off
Link Road, Ghatkopar (E), Mumbai 400 075, India)
Abstract
Aim of our study was to evaluate the beneficial effect of low dose
intrathecal morphine on postoperative analgesia, over the use of
intravenous patient controlled anesthesia (PCA), in patients undergoing
fast track anesthesia during minimally invasive cardiac surgical
procedures. A randomized controlled trial was undertaken after approval
from local ethical committee. Written informed consent was obtained from
61 patients receiving mitral or tricuspid or both surgical valve repair in
minimal invasive technique. Patients were assigned randomly to 2 groups.
Group 1 received general anesthesia and intravenous patient controlled
analgesia (PCA) pump with Piritramide (GA group). Group 2 received a
single shot of intrathecal morphine (1.5 g/kg body weight) prior to the
administration of general anesthesia (ITM group). Site of puncture was
confined to lumbar (L1-2 or L2-3) intrathecal space. The amount of
intravenous piritramide used in post anesthesia care unit (PACU) and the
first postoperative day was defined as primary end point. Secondary end
points included: time for tracheal extubation, pain and sedation scores in
PACU upto third postoperative day. For statistical analysis Mann-Whitney-U
Test and Fishers exact test (SPSS) were used. We found that the demand for
intravenous opioids in PACU was significantly reduced in ITM group (P
<0.001). Pain scores were significantly decreased in ITM group until
second postoperative day (P <0.01). There was no time delay for tracheal
extubation in ITM group, and sedation scores did not differ in either
group. We conclude that low dose single shot intrathecal morphine provides
adequate postoperative analgesia, reduces the intravenous opioid
consumption during the early postoperative period and does not defer early
extubation.

<4>
Accession Number
2012248280
Authors
Chakravarthy M. Muniraj G. Patil S. Suryaprakash S. Mitra S. Shivalingappa
B.
Institution
(Chakravarthy, Muniraj, Patil, Suryaprakash, Mitra, Shivalingappa)
Department of Anesthesia, Critical Care and Pain Management, Fortis
Hospitals, Bannerghatta Road, Bangalore, India
Title
A randomized prospective analysis of alteration of hemostatic function in
patients receiving tranexamic acid and hydroxyethyl starch (130/0.4)
undergoing off pump coronary artery bypass surgery.
Source
Annals of Cardiac Anaesthesia. 15 (2) (pp 105-110), 2012. Date of
Publication: April-June 2012.
Publisher
Medknow Publications and Media Pvt. Ltd (B9, Kanara Business Centre, off
Link Road, Ghatkopar (E), Mumbai 400 075, India)
Abstract
Postoperative hemorrhagic complications is still one of the major problems
in cardiac surgeries. It may be caused by surgical issues, coagulopathy
caused by the side effects of the intravenous fluids administered to
produce plasma volume expansion such as hydroxyl ethyl starch (HES). In
order to thwart this hemorrhagic issue, few agents are available.
Fibrinolytic inhibitors like tranexamic acid (TA) may be effective modes
to promote blood conservation; but the possible complications of
thrombosis of coronary artery graft, precludes their generous use in
coronary artery bypass graft surgery. The issue is a balance between
agents that promote coagulation and those which oppose it. Therefore, in
this study we have assessed the effects of concomitant use of HES and TA.
Thromboelastogram (TEG) was used to assess the effect of the combination
of HES and TA. With ethical committee approval and patient's consent, 100
consecutive patients were recruited for the study. Surgical and anesthetic
techniques were standardized. Patients fulfilling our inclusion criteria
were randomly allocated into 4 groups of 25 each. The patients in group A
received 20 ml/kg of HES (130/0.4), 10 mg/kg of T.A over 30 minutes
followed by infusion of 1 mg/kg/hr over the next 12 hrs. The patients in
group B received Ringer's lactate + TA at same dose. The patients in the
Group C received 20 ml/kg of HES. Group D patients received RL. Fluid
therapy was goal directed. Total blood loss was assessed. Reaction time
(r), alpha angle, maximum amplitude (MA) values of TEG were assessed at
baseline, 12, 36 hrs. The possible perioperative myocardial infraction
(MI) was assessed by electrocardiogram (ECG) and troponin T values at the
baseline, postoperative day 1. Duration on ventilator, length of stay
(LOS) in the intensive care unit (ICU) were also assessed. The
demographical profile was similar among the groups. Use of HES increased
blood loss significantly (P < 0.05). Concomitant use of TA reduced blood
loss when used along with HES. r value was prolonged at 12 hours in all
the groups and angle was reduced at 12 hours in all the groups, where as
MA value was reduced at 12 ^th hour in the HES group compared to
the baseline and increased in TA + HES group. These findings were
statistically significant. No significant change in Troponin T values/
ECG, duration of ventilation and LOS ICU was observed. No adverse events
was noticed in any of the four groups. HES (130/0.4) used at a dose of 20
ml/kg seems to produce coagulopathy causing increased blood loss
perioperatively. Hemodilution produced by fluid therapy seems to produce
Coagulopathy as observed by TEG parameters. Concomitant use of TA with HES
appears to reverse these changes without causing any adverse effects in
patients undergoing OPCAB surgery.

<5>
Accession Number
2012247757
Authors
Gilard M. Eltchaninoff H. Iung B. Donzeau-Gouge P. Chevreul K. Fajadet J.
Leprince P. Leguerrier A. Lievre M. Prat A. Teiger E. Lefevre T. Himbert
D. Tchetche D. Carrie D. Albat B. Cribier A. Rioufol G. Sudre A. Blanchard
D. Collet F. Dos Santos P. Meneveau N. Tirouvanziam A. Caussin C. Guyon P.
Boschat J. Le Breton H. Collart F. Houel R. Delpine S. Souteyrand G.
Favereau X. Ohlmann P. Doisy V. Grollier G. Gommeaux A. Claudel J.-P.
Bourlon F. Bertrand B. Van Belle E. Laskar M.
Institution
(Gilard, Boschat) Centre Hospitalier Universitaire (CHU) Brest, Brest,
France
(Eltchaninoff, Cribier) Hopital Charles Nicolle, University of Rouen,
INSERM Unite 1096, Rouen, France
(Iung, Himbert) Bichat Hospital, Paris, France
(Chevreul, Teiger) CHU Henri Mondor, Paris, France
(Leprince) Pitie-Salpetriere Hospital, Paris, France
(Donzeau-Gouge, Lefevre) Institut Jacques Cartier, Massy, France
(Fajadet, Tchetche) Clinique Pasteur, Toulouse, France
(Carrie) CHU Toulouse, Toulouse, France
(Leguerrier, Le Breton) CHU Rennes, Rennes, France
(Lievre) University Lyon 1, Lyon, France
(Doisy) Clinique Tonkin, Lyon, France
(Claudel) Infirmerie Protestante, Lyon, France
(Prat, Sudre, Van Belle) CHU Lille, Lille, France
(Albat) CHU Montpellier, Montpellier, France
(Blanchard) Clinique St. Gatien, Tours, France
(Rioufol) CHU Lyon, Bron, France
(Collet, Collart) Hopital Clairval, Marseille, France
(Houel) Hopital St. Joseph, Marseille, France
(Collet, Collart) Hopital La Timone, Marseille, France
(Caussin) Hopital Marie Lannelongue, Le Plessis-Robinson, France
(Meneveau) CHU Besancon, Besancon, France
(Guyon) Centre Cardiologique du Nord, Saint-Denis, France
(Dos Santos) CHU Bordeaux, Bordeaux, France
(Tirouvanziam) CHU Nantes, Nantes, France
(Delpine) CHU Angers, Angers, France
(Souteyrand) CHU Clermont-Ferrand, Clermont-Ferrand, France
(Favereau) Parly 2, Le Chesnay, France
(Ohlmann) CHU Strasbourg, Strasbourg, France
(Grollier) CHU Caen, Caen, France
(Gommeaux) Polyclinique Bois-Bernard, Bois-Bernard, France
(Bertrand) CHU Grenoble, Grenoble, France
(Laskar) CHU Dupuytren, Limoges, France
(Bourlon) Centre Cardiothoracique, Monte Carlo, Monaco
Title
Registry of transcatheter aortic-valve implantation in high-risk patients.
Source
New England Journal of Medicine. 366 (18) (pp 1705-1715), 2012. Date of
Publication: 03 May 2012.
Publisher
Massachussetts Medical Society (860 Winter Street, Waltham MA 02451-1413,
United States)
Abstract
Background: Transcatheter aortic-valve implantation (TAVI) is an emerging
intervention for the treatment of high-risk patients with severe aortic
stenosis and coexisting illnesses. We report the results of a prospective
multicenter study of the French national transcatheter aortic-valve
implantation registry, FRANCE 2. Methods: All TAVIs performed in France,
as listed in the FRANCE 2 registry, were prospectively included in the
study. The primary end point was death from any cause. Results: A total of
3195 patients were enrolled between January 2010 and October 2011 at 34
centers. The mean (+/-SD) age was 82.7+/-7.2 years; 49% of the patients
were women. All patients were highly symptomatic and were at high surgical
risk for aortic-valve replacement. Edwards SAPIEN and Medtronic CoreValve
devices were implanted in 66.9% and 33.1% of patients, respectively.
Approaches were either transarterial (transfemoral, 74.6%; subclavian,
5.8%; and other, 1.8%) or transapical (17.8%). The procedural success rate
was 96.9%. Rates of death at 30 days and 1 year were 9.7% and 24.0%,
respectively. At 1 year, the incidence of stroke was 4.1%, and the
incidence of periprosthetic aortic regurgitation was 64.5%. In a
multivariate model, a higher logistic risk score on the European System
for Cardiac Operative Risk Evaluation (EuroSCORE), New York Heart
Association functional class III or IV symptoms, the use of a transapical
TAVI approach, and a higher amount of periprosthetic regurgitation were
significantly associated with reduced survival. Conclusions: This
prospective registry study reflected real-life TAVI experience in
high-risk elderly patients with aortic stenosis, in whom TAVI appeared to
be a reasonable option. (Funded by Edwards Lifesciences and Medtronic.)
Copyright 2012 Massachusetts Medical Society.

<6>
Accession Number
2012247756
Authors
Makkar R.R. Fontana G.P. Jilaihawi H. Kapadia S. Pichard A.D. Douglas P.S.
Thourani V.H. Babaliaros V.C. Webb J.G. Herrmann H.C. Bavaria J.E. Kodali
S. Brown D.L. Bowers B. Dewey T.M. Svensson L.G. Tuzcu M. Moses J.W.
Williams M.R. Siegel R.J. Akin J.J. Anderson W.N. Pocock S. Smith C.R.
Leon M.B.
Institution
(Makkar, Jilaihawi, Siegel) Cedars-Sinai Heart Institute, Los Angeles, CA,
United States
(Fontana) Lenox Hill Heart, Vascular Institute, New York, NY, United
States
(Kodali, Moses, Williams, Smith, Leon) Columbia University Medical Center,
New York Presbyterian Hospital, New York, NY, United States
(Kapadia, Svensson, Tuzcu) Cleveland Clinic Foundation, Cleveland, OH,
United States
(Pichard) Washington Hospital Center, Washington, DC, United States
(Douglas) Duke University School of Medicine, Durham, NC, United States
(Thourani, Babaliaros) Emory University School of Medicine, Atlanta, GA,
United States
(Webb) University of British Columbia, St. Paul's Hospital, Vancouver, BC,
Canada
(Herrmann, Bavaria) Hospital of the University of Pennsylvania,
Philadelphia, PA, United States
(Brown) Baylor Healthcare System, Dallas, TX, United States
(Bowers) Medical City Dallas, Dallas, TX, United States
(Dewey, Anderson) Edwards Lifesciences, Irvine, CA, United States
(Akin, Pocock) London School of Hygiene and Tropical Medicine, London,
United Kingdom
Title
Transcatheter aortic-valve replacement for inoperable severe aortic
stenosis.
Source
New England Journal of Medicine. 366 (18) (pp 1696-1704), 2012. Date of
Publication: 03 May 2012.
Publisher
Massachussetts Medical Society (860 Winter Street, Waltham MA 02451-1413,
United States)
Abstract
BACKGROUND: Transcatheter aortic-valve replacement (TAVR) is the
recommended therapy for patients with severe aortic stenosis who are not
suitable candidates for surgery. The outcomes beyond 1 year in such
patients are not known. METHODS: We randomly assigned patients to
transfemoral TAVR or to standard therapy (which often included balloon
aortic valvuloplasty). Data on 2-year outcomes were analyzed. RESULTS: A
total of 358 patients underwent randomization at 21 centers. The rates of
death at 2 years were 43.3% in the TAVR group and 68.0% in the
standard-therapy group (P<0.001), and the corresponding rates of cardiac
death were 31.0% and 62.4% (P<0.001). The survival advantage associated
with TAVR that was seen at 1 year remained significant among patients who
survived beyond the first year (hazard ratio, 0.58; 95% confidence
interval [CI], 0.36 to 0.92; P = 0.02 with the use of the log-rank test).
The rate of stroke was higher after TAVR than with standard therapy (13.8%
vs. 5.5%, P = 0.01), owing, in the first 30 days, to the occurrence of
more ischemic events in the TAVR group (6.7% vs. 1.7%, P = 0.02) and,
beyond 30 days, to the occurrence of more hemorrhagic strokes in the TAVR
group (2.2% vs. 0.6%, P = 0.16). At 2 years, the rate of rehospitalization
was 35.0% in the TAVR group and 72.5% in the standard-therapy group
(P<0.001). TAVR, as compared with standard therapy, was also associated
with improved functional status (P<0.001). The data suggest that the
mortality benefit after TAVR may be limited to patients who do not have
extensive coexisting conditions. Echocardiographic analysis showed a
sustained increase in aortic-valve area and a decrease in aortic-valve
gradient, with no worsening of paravalvular aortic regurgitation.
CONCLUSIONS: Among appropriately selected patients with severe aortic
stenosis who were not suitable candidates for surgery, TAVR reduced the
rates of death and hospitalization, with a decrease in symptoms and an
improvement in valve hemodynamics that were sustained at 2 years of
follow-up. The presence of extensive coexisting conditions may attenuate
the survival benefit of TAVR. Copyright 2012 Massachusetts Medical
Society.

<7>
Accession Number
2012247755
Authors
Kodali S.K. Williams M.R. Smith C.R. Svensson L.G. Webb J.G. Makkar R.R.
Fontana G.P. Dewey T.M. Thourani V.H. Pichard A.D. Fischbein M. Szeto W.Y.
Lim S. Greason K.L. Teirstein P.S. Malaisrie S.C. Douglas P.S. Hahn R.T.
Whisenant B. Zajarias A. Wang D. Akin J.J. Anderson W.N. Leon M.B.
Institution
(Kodali, Williams, Smith, Hahn, Leon) Columbia University Medical Center,
New York Presbyterian Hospital, 161 Fort Washington Ave., New York, NY
10032, United States
(Fontana) Lenox Hill Hospital, New York, NY, United States
(Svensson) Cleveland Clinic Foundation, Cleveland, OH, United States
(Webb) University of British Columbia, St. Paul's Hospital, Vancouver, BC,
Canada
(Makkar) Cedars-Sinai Medical Center, Los Angeles, CA, United States
(Dewey) Medical City Dallas, Dallas, TX, United States
(Thourani) Emory University School of Medicine, Atlanta, GA, United States
(Pichard) Washington Hospital Center, Washington, DC, United States
(Fischbein) Stanford University Medical School, Palo Alto, CA, United
States
(Teirstein) Scripps Clinic, San Diego, CA, United States
(Akin, Anderson) Edwards Lifesciences, Irvine, CA, United States
(Szeto) Hospital of the University of Pennsylvania, Philadelphia, PA,
United States
(Lim) University of Virginia, Charlottesville, VA, United States
(Greason) Mayo Clinic, Rochester, MN, United States
(Malaisrie) Northwestern University, Chicago, IL, United States
(Douglas) Duke University Medical Center, Durham, NC, United States
(Whisenant) Intermountain Medical Center, Salt Lake City, UT, United
States
(Zajarias) Washington University Medical School, Barnes-Jewish Hospital,
St. Louis, WA, United States
(Wang) London School of Hygiene and Tropical Medicine, London, United
Kingdom
Title
Two-year outcomes after transcatheter or surgical aortic-valve
replacement.
Source
New England Journal of Medicine. 366 (18) (pp 1686-1695), 2012. Date of
Publication: 03 May 2012.
Publisher
Massachussetts Medical Society (860 Winter Street, Waltham MA 02451-1413,
United States)
Abstract
BACKGROUND: The Placement of Aortic Transcatheter Valves (PARTNER) trial
showed that among high-risk patients with aortic stenosis, the 1-year
survival rates are similar with transcatheter aortic-valve replacement
(TAVR) and surgical replacement. However, longerterm follow-up is
necessary to determine whether TAVR has prolonged benefits. METHODS: At 25
centers, we randomly assigned 699 high-risk patients with severe aortic
stenosis to undergo either surgical aortic-valve replacement or TAVR. All
patients were followed for at least 2 years, with assessment of clinical
outcomes and echocardiographic evaluation. RESULTS: The rates of death
from any cause were similar in the TAVR and surgery groups (hazard ratio
with TAVR, 0.90; 95% confidence interval [CI], 0.71 to 1.15; P = 0.41) and
at 2 years (Kaplan-Meier analysis) were 33.9% in the TAVR group and 35.0%
in the surgery group (P = 0.78). The frequency of all strokes during
follow-up did not differ significantly between the two groups (hazard
ratio, 1.22; 95% CI, 0.67 to 2.23; P = 0.52). At 30 days, strokes were
more frequent with TAVR than with surgical replacement (4.6% vs. 2.4%, P =
0.12); subsequently, there were 8 additional strokes in the TAVR group and
12 in the surgery group. Improvement in valve areas was similar with TAVR
and surgical replacement and was maintained for 2 years. Paravalvular
regurgitation was more frequent after TAVR (P<0.001), and even mild
paravalvular regurgitation was associated with increased late mortality
(P<0.001). CONCLUSIONS: A 2-year follow-up of patients in the PARTNER
trial supports TAVR as an alternative to surgery in high-risk patients.
The two treatments were similar with respect to mortality, reduction in
symptoms, and improved valve hemodynamics, but paravalvular regurgitation
was more frequent after TAVR and was associated with increased late
mortality. Copyright 2012 Massachusetts Medical Society.

<8>
Accession Number
2012248447
Authors
Campbell J. Holland C. Richens D. Skinner H.
Institution
(Campbell) Clinical Perfusion, Nottingham University Hospitals NHS Trust,
United Kingdom
(Holland) Haematology, Nottingham University Hospitals NHS Trust, United
Kingdom
(Richens) Cardiac Surgery, Nottingham University Hospitals NHS Trust,
United Kingdom
(Skinner) Department of Anaesthesia, Nottingham University Hospitals NHS
Trust, Nottingham NG5 1PB, United Kingdom
Title
Impact of cell salvage during cardiac surgery on the thrombelastomeric
coagulation profile: A pilot study.
Source
Perfusion. 27 (3) (pp 221-224), 2012. Date of Publication: May 2012.
Publisher
SAGE Publications Ltd (55 City Road, London EC1Y 1SP, United Kingdom)
Abstract
Intraoperative cell salvage of the cardiopulmonary bypass residual volume
can dilute platelets and coagulation factors. This is a report of a
randomised control trial of 20 patients undergoing coronary bypass
surgery. Residual cardiopulmonary bypass volume was processed and
transfused after surgery in the cell salvage group and the residual volume
was transfused unprocessed in the control group. The coagulation profile
was measured using the Rotem thrombelastometry system. Mean (SD) maximum
clot firmness after surgery was 52.8 (5.4) mm in the cell salvage group
compared to 57.2 (5.0) mm in the control group (p=0.04). Clot formation
time was prolonged after surgery by 39 (27) s in the cell saver group
compared to 19 (17) s in the control group (p=0.045). Platelet count was
reduced after surgery by 96 (32) x 109.L-1 in the cell saver group and 70
(19) x 109.L-1 in the control group (p=0.03). Blood volume in the chest
drains 4 hours after surgery was similar in both groups. There was a
strong association between clot formation time after surgery and blood
loss (R = 0.68, p=0.001). The increase in blood loss was 4.1 ml for every
one-second increase in clot formation time (95% CI 1.9-6.4, p=0.001). Cell
salvage of the residual cardiopulmonary bypass volume reduced platelet
numbers and prolonged clot formation time and maximum clot firmness was
less in this group. The Author(s) 2011.

<9>
Accession Number
2012246794
Authors
Ang L.B. Veloria E.N. Evanina E.Y. Smaldone A.
Institution
(Ang, Veloria, Evanina) Doctor of Nursing Practice Program, Columbia
University School of Nursing, New York, NY, United States
(Ang) Intensive Care Unit, Straub Clinic and Hospital, Honolulu, HI,
United States
(Veloria) Cardiothoracic Intensive Care Unit, Surgical Intensive Care Unit
New York Presbyterian, Columbia Univ. Medical Center, New York, NY, United
States
(Evanina) Program in Nurse Anesthesia, Columbia University School of
Nursing, New York, NY, United States
(Smaldone) Doctor of Nursing Practice Program, Columbia University School
of Nursing, New York, NY, United States
Title
Mediastinitis and blood transfusion in cardiac surgery: A systematic
review.
Source
Heart and Lung: Journal of Acute and Critical Care. 41 (3) (pp 255-263),
2012. Date of Publication: May 2012.
Publisher
Mosby Inc. (11830 Westline Industrial Drive, St. Louis MO 63146, United
States)
Abstract
Background: Mediastinitis, a serious complication after cardiac surgery,
increases morbidity, mortality, and cost of care. Accumulating evidence
implicates blood transfusions in the development of mediastinitis.
Objectives: We conducted a systematic review to evaluate the association
between allogeneic blood transfusion and mediastinitis in adult cardiac
surgery patients. Results: After a search of Medline, PubMed, Cochrane
Library, the Cumulative Index to Nursing and Allied Health Literature, and
the Institute for Scientific Information's Web of Knowledge (1990-2010)
for relevant studies, 7 (3 prospective cohort and 4 retrospective reviews)
met our inclusion/exclusion criteria. Between 20% and 80.2% of patients
received blood transfusions, with an incidence of mediastinitis ranging
from 0.1% to 2.3%. Five studies demonstrated an independent association
between red blood cell transfusion and mediastinitis. Two studies
identified a dose-response relationship. Conclusion: The findings of this
systematic review suggest that allogeneic red blood cell transfusions are
associated with an increased risk of mediastinitis in patients undergoing
cardiac surgery. Individual risks and benefits should be assessed in each
patient before a red blood cell transfusion. 2012 Elsevier Inc.

<10>
Accession Number
2012253484
Authors
Hopp E. Lunde K. Solheim S. Aakhus S. Arnesen H. Forfang K. Edvardsen T.
Smith H.-J.
Institution
(Hopp, Smith) Department of Radiology, Oslo University Hospital,
Rikshospitalet, Postbox 4950, Nydalen, 0424 Oslo, Norway
(Lunde, Aakhus, Forfang, Edvardsen) Department of Cardiology, Oslo
University Hospital, Rikshospitalet, Norway
(Solheim, Arnesen) Department of Cardiology, Oslo University Hospital,
Ulleval, Norway
(Arnesen) Faculty of Medicine, University of Oslo, Oslo, Norway
Title
Regional myocardial function after intracoronary bone marrow cell
injection in reperfused anterior wall infarction - A cardiovascular
magnetic resonance tagging study.
Source
Journal of Cardiovascular Magnetic Resonance. 13 (1) , 2011. Article
Number: 22. Date of Publication: 2011.
Publisher
BioMed Central Ltd. (Floor 6, 236 Gray's Inn Road, London WC1X 8HB, United
Kingdom)
Abstract
Background: Trials have brought diverse results of bone marrow stem cell
treatment in necrotic myocardium. This substudy from the Autologous Stem
Cell Transplantation in Acute Myocardial Infarction trial (ASTAMI)
explored global and regional myocardial function after intracoronary
injection of autologous mononuclear bone marrow cells (mBMC) in acute
anterior wall myocardial infarction treated with percutaneous coronary
intervention. Methods. Cardiovascular magnetic resonance (CMR) tagging was
performed 2-3 weeks and 6 months after revascularization in 15 patients
treated with intracoronary stem cell injection (mBMC group) and in 13
controls without sham injection. Global and regional left ventricular (LV)
strain and LV twist were correlated to cine CMR and late gadolinium
enhancement (LGE). Results: In the control group myocardial function as
measured by strain improved for the global LV (6 months: -13.1 2.4 versus
2-3 weeks: -11.9 3.4%, p = 0.014) and for the infarct zone (-11.8 3.0
versus -9.3 4.1%, p = 0.001), and significantly more than in the mBMC
group (inter-group p = 0.027 for global strain, respectively p = 0.009 for
infarct zone strain). LV infarct mass decreased (35.7 20.4 versus 45.7
29.5 g, p = 0.024), also significantly more pronounced than the mBMC group
(inter-group p = 0.034). LV twist was initially low and remained unchanged
irrespective of therapy. Conclusions: LGE and strain findings quite
similarly demonstrate subtle differences between the mBMC and control
groups. Intracoronary injection of autologous mBMC did not strengthen
regional or global myocardial function in this substudy. Trial
registration. ClinicalTrials.gov: NCT00199823. 2011 Hopp et al; licensee
BioMed Central Ltd.

<11>
Accession Number
70738283
Authors
Bashir J.G. Karim S. Danter M. Cowan S. Tyers G.
Institution
(Bashir, Karim, Danter, Cowan, Tyers) St. Paul's Hospital, Vancouver, BC,
Canada
(Bashir, Karim, Danter, Cowan, Tyers) University of British Columbia,
Vancouver, BC, Canada
Title
Canadian lead extraction risk score (clear score): A proposal for a novel
risk scoring system for lead extraction.
Source
Heart Rhythm. Conference: 33rd Annual Scientific Sessions of the Heart
Rhythm Society, Heart Rhythm 2012 Boston, MA United States. Conference
Start: 20120509 Conference End: 20120512. Conference Publication:
(var.pagings). 9 (5 SUPPL. 1) (pp S69), 2012. Date of Publication: May
2012.
Publisher
Elsevier
Abstract
Introduction: Laser lead extraction is a proven effective treatment for
the removal of retained lead hardware. It is, however, associated with a
small but significant risk to the patient. While large multi-centre
studies have pursued variables associated with this risk, no objective way
of scoring this risk has previously been proposed. As such we created a
novel risk scoring system for laser lead extraction and validated it based
on our experience. Methods: Risk scoring systems such as the STS score and
Euroscore are well validated tools for the pre-operative evaluation of
surgical patients. No equivalent system is available for pacemaker or ICD
lead extraction. We undertook a systematic review of the literature to
determine the variables associated with major complication and used these
to establish a risk score. The score delineates the risk of a Life
Threatening Complication (LTC) (such as need for thoracotomy). Points are
added for each of the following clinical characteristics as follows:
female sex (+2), low BMI <26 (+1), operator experience 100 cases (+0),
lead implant duration >8 yrs (+2), lead implant duration <8 yrs (+0), no
previous cardiac surgery (+1), previous cardiac surgery (-2). Add 2 to
total. Max score 10. Min score 0. Results: To validate the score we
performed a retrospective analysis of the over 1000 patients in our
centers lead extraction experience. We then scored each of the patients
who had a major complication in the form of a perforation requiring
thoracotomy since 2001. These life threatening complications were
identified in 12 patients. The mean score for LTC was 7.67 and the median
score was 7.5. The minimum score was 5 in one patient while 3 patients
scored a 10and 3 patients scored an 8. Conclusions: We present a novel
risk scoring system for lead extraction. This was well validated by our
own experience as all patients who had a life threatening complication
scored 5 or more and most patients scored over 7. Further validation of
the score is required. We believe that utilization of this scoring system
will be effective at mitigating risk primarily by ensuring that high risk
patients are identified. The presence of a high risk score could also
mandate that surgical back-up be immediately available or allow the
operator to explore other options.

<12>
Accession Number
70735290
Authors
Haase M. Mertens P. Plas M. Bellomo R. Haase-Fielitz A.
Institution
(Haase, Mertens, Haase-Fielitz) Otto-von-Guericke University, Magdeburg,
Germany
(Plas) German Heart Center, Berlin, Germany
(Bellomo) Austin Health, Melbourne, Australia
Title
Neutrophil gelatinase-associated lipocalin predicts postoperative fluid
overload, a potentially modifiable risk factor for mortality after cardiac
surgery.
Source
Critical Care. Conference: 32nd International Symposium on Intensive Care
and Emergency Medicine Brussels Belgium. Conference Start: 20120320
Conference End: 20120323. Conference Publication: (var.pagings). 16 (pp
S126), 2012. Date of Publication: 20 Mar 2012.
Publisher
BioMed Central Ltd.
Abstract
Introduction: In most previous studies, neutrophil gelatinaseassociated
lipocalin (NGAL), measured immediately following cardiac surgery, has been
demonstrated to predict postoperative increases in serum creatinine and
decline in urine output. In patients undergoing cardiac surgery,
postoperative fluid overload is a typical complication. In this study, we
investigated the early postoperative value of NGAL to predict subsequent
fluid overload, a potentially modifiable risk factor in these patients.
Methods We studied 100 adult cardiac surgery patients assigned to the
control arm of a randomized controlled trial. Urine and serum were sampled
immediately after admission to the ICU. Urine NGAL was measured on the
ARCHITECT laboratory platform (Abbott Diagnostics) and serum creatinine
using an enzymatic assay. Postoperative fluid overload was defined as
positive fluid balance with >10% excess of preoperative body weight within
48 hours. An area under the curve of the receiver-operating
characteristics (AUC-ROC) of 0.5 indicates the predictive ability equaling
the toss of a coin and >0.7 of a useful biomarker. Results Postoperative
fluid overload was present in 15% of patients with a mean positive fluid
balance of 12 +/- 9 kg. Patients who survived the hospital stay had a
lower positive fluid balance of 2.8 l (25th to 75th percentiles: 1.5 to
5.5) compared to patients who died (23.0 l (25th to 75th percentiles: 14.5
to 24.0)); P = 0.010. A positive fluid balance predicted in-hospital
mortality with AUC 0.94 (95% CI 0.83 to 0.99), sensitivity 100% and
specificity 80% at a cut-off >6 l. Urine NGAL predicted fluid overload
(AUC-ROC 0.80 (95% CI 0.64 to 0.93)) and mortality (AUC-ROC 0.88 (95% CI
0.78 to 0.97)). Serum creatinine did not predict fluid overload (AUC-ROC
0.51 (95% CI 0.24 to 0.78)) or mortality (AUC-ROC 0.61 (95% CI 0.16 to
0.99)). Conclusion Fluid overload frequently occurs during the first 48
hours after cardiac surgery and is strongly correlated with postoperative
mortality. Early postoperatively measured urine NGAL is a good predictor
of fluid overload and mortality whereas measurement of serum creatinine at
the same time equals the toss of a coin. Early NGALguided adjustments of
fluid management might reduce organ edema and potentially improve patient
outcomes after cardiac surgery. Our findings should be validated in larger
patient cohorts.

<13>
Accession Number
70735282
Authors
Hammond N. Bass F. Shehabi Y.
Institution
(Hammond, Bass, Shehabi) Prince of Wales Hospital, Randwick, Australia
Title
Memories and post-traumatic stress-related symptoms in older, post-cardiac
surgery patients: Substudy of an RCT.
Source
Critical Care. Conference: 32nd International Symposium on Intensive Care
and Emergency Medicine Brussels Belgium. Conference Start: 20120320
Conference End: 20120323. Conference Publication: (var.pagings). 16 (pp
S123), 2012. Date of Publication: 20 Mar 2012.
Publisher
BioMed Central Ltd.
Abstract
Introduction: The majority of ICU survivors display little evidence of
severe psychological sequelae. However, there is evidence of posttraumatic
stress disorder (PTSD)-related symptoms such as anxiety, depression, panic
attacks, distressing memories and flashbacks within the first 3 months
post ICU discharge [1,2]. This substudy of the DEXCOM trial 3 (randomised
controlled trial of neurobehavioural effects of dexmedetomidine or
morphine for sedation and analgesia in patients 60 years or older,
undergoing coronary artery bypass grafting and/or valve replacement) aims
to explore any negative memories of the ICU and development of
PTSD-related symptoms between treatment groups of patients at high risk of
developing delirium. Methods At 8 weeks post ICU discharge, patients
completed three assessment tools, by mail or telephone. Tools used were
Depression Anxiety Stress Scale, ICU memory assessment tool and impact of
events scale. Results A total of 153 patients completed the substudy; 72
patients in the [M]orphine group and 81 in the [D]exmedetomidine group.
The mean age (years) in the M group was 72 (SD 5) and in the D group 69
(SD 6), with 71% (n = 51) males in the M group and 84% (n = 68) in the D
group. The mean ICU hours for M and D were 58 (SD 40) and 48 (SD 32)
respectively. No significant differences of memories or PTSDrelated
symptoms between the two treatment groups, for each of the three
assessment tools, were found. From the ICU memory tool, 21% (n = 15/70) of
M group patients and 15% (n = 12/81) of the D patients remember being in
the ICU. Just over one-half of the patients in both groups did not
remember all of their ICU stay with clarity (M group: 54%, n = 39/72; D
group: 51%, n = 40/78). Furthermore, 23% (n = 15/64) of M patients and 14%
(n = 10/73) of D patients had intrusive memories whilst in the ICU.
Conclusion Patients undergoing cardiac surgery with ICU stay do not have
clear memories of this episode. A small number had intrusive memories,
which are more common in M patients. The study used a convenience sample
so was not powered to detect a significant difference. No differences in
factual or delusional memories or PTSDrelated symptoms between the
treatment groups were found. These data could be the basis of a sample
size calculation for a larger study.

<14>
Accession Number
70735137
Authors
Osawa E. Rhodes A. Fukushima J. Almeida J. Jatene F. Nakamura R. Sundin M.
Auler J. Kalil Filho R. Galas F. Hajjar L.
Institution
(Osawa, Fukushima, Almeida, Jatene, Nakamura, Sundin, Auler, Kalil Filho,
Galas, Hajjar) Heart Institute, Sao Paulo, Brazil
(Rhodes) Charing Cross Hospital, Imperial College NHS Trust, London,
United Kingdom
Title
Goal-directed hemodynamic resuscitation in high-risk patients undergoing
cardiac surgery: A randomized controlled trial - Preliminary data (GRICCS
STUDY).
Source
Critical Care. Conference: 32nd International Symposium on Intensive Care
and Emergency Medicine Brussels Belgium. Conference Start: 20120320
Conference End: 20120323. Conference Publication: (var.pagings). 16 (pp
S71), 2012. Date of Publication: 20 Mar 2012.
Publisher
BioMed Central Ltd.
Abstract
Introduction Low cardiac output is a frequent clinical circumstance after
cardiac surgery and results in higher morbidity and mortality rates.
Goal-directed therapy (GDT) is a validated design that has been proved to
reduce the number of perioperative outcomes. We investigated the results
of a cardiac index optimization protocol through the use of the LiDCO
rapid device. Methods A prospective study that randomized 34 high-risk
patients (EuroSCORE higher than 6 or LVEF lower than 45%) to a GDT
protocol or a conventional hemodynamic therapy. Patients from the GDT
group were resuscitated to a cardiac index higher than 3 l/minute/m2
through the implementation of a three-step approach: (1) fluid challenge
of 250 ml aliquots, (2) dobutamine infusion up to a dose of 20
mug/kg/minute, and (3) blood transfusion to reach a hematocrit higher than
28%. The control group was managed according to institutional protocol.
Categorical variables were compared using Fisher's exact test and
categorical variables were compared using the Mann-Whitney U test. Results
Sixteen patients from the GDT group were compared with 18 patients from
the control group. There was a tendency towards reduction in ICU stay in
patients from GDT group in relation to the control group (7 days vs. 6
days, P = 0.18). Comparison of the primary endpoint variable (composite of
death or major postoperative complications within 30 days after surgery or
before discharge) between groups showed a reduced complication rate in the
GDT group (52.2% vs. 45.6%, P = 0.12), mainly attributed to worse acute
renal failure RIFLE criteria in the control group. Conclusion
Goal-directed hemodynamic resuscitation with the use of a minimally
invasive device seems to be a promising perioperative strategy aimed at
reducing the rates of worse outcomes and the ICU stay after cardiac
surgery.

<15>
Accession Number
70734578
Authors
Shah K.B. Flattery M.P. Doolin K.
Institution
(Shah, Flattery, Doolin) Pauley Heart Center, Virginia Commonwealth
University Health System, Richmond, VA, United States
Title
Women in a predominantly african american population exhibit lower gene
expression scores early after heart transplant.
Source
Journal of Heart and Lung Transplantation. Conference: 32nd Annual Meeting
and Scientific Sessions of the International Society for Heart and Lung
Transplantation Prague Czech Republic. Conference Start: 20120418
Conference End: 20120421. Conference Publication: (var.pagings). 31 (4
SUPPL. 1) (pp S167-S168), 2012. Date of Publication: April 2012.
Publisher
Elsevier USA
Abstract
Purpose: Gene expression profiling (GEP) (Allomap, XDx, Brisbane, CA), an
alternative to endomyocardial biopsy for surveillance of cellular
rejection was validated in a randomized controlled trial for patients
(pts) >6 mo. post heart transplant (HT). We evaluated the impact of immune
therapies (rx) and demographic variables on GEP >6 months after HT.
Methods and Materials: We abstracted data for patients with GEP performed
2-6 mo. post HT. Continuous variables were compared with t-tests and
categorical variables with chi². Results: We evaluated 93 GEP
scores in 44 pts (51yrs, 59% AA, 33% women). Mean scores=19+/-7 at 84+/-14
days after HT and increased to 24+/-6 by 180+/-8 days (P=0.02). Scores had
inverse relationships with tacrolimus (TAC) dose (beta [95%CI] =
beta0.18[beta0.57,beta0.12]), prednisone dose (beta [95%CI]=
beta0.42[beta0.67,beta0.43]) and TAC level (beta [95%CI] =
beta0.16[beta0.64,beta0.09]). Women had lower scores at initial
measurement (15+/-8 vs 21+/-7, P=0.048). Age, induction and maintenance rx
were similar for both genders. At the 3 mo. GEP, mean TAC dose (8.1+/-1.2
mg vs 8.5+/-3.9 mg, P=NS), TAC level (7.3+/-2.2 vs 8.6+/-3.1, P=NS) and
prednisone dose (14.4+/-5.0 mg vs 13.6+/-3.1 mg, P=NS) did not differ by
gender. Nearly the entire female cohort were AA (88% vs 50% of the men;
P=0.07) and men had higher serum creatinine (0.8+/-0.2 mg/dL vs 1.3+/-0.4
mg/dL, P=0.002). (Figure presented) Conclusions: In this single center
study, a predominantly AA cohort of women had lower GEP scores than men
early after HT despite similar immune modulating rx. Gender specific
sensitivity of the GEP to clinical events and immune rx early post HT may
exist. Further studies examining the interaction of race, gender and
components of the GEP are needed.

<16>
Accession Number
70734458
Authors
Guglin M. Mehra S. Mason T.
Institution
(Guglin) Cardiology, University of South Florida, Tampa, FL, United States
(Mehra, Mason) College of Public Health, University of South Florida,
Tampa, FL, United States
Title
Comparative effects of the drugs used for pulmonary hypertension
reversibility testing: A meta-analysis.
Source
Journal of Heart and Lung Transplantation. Conference: 32nd Annual Meeting
and Scientific Sessions of the International Society for Heart and Lung
Transplantation Prague Czech Republic. Conference Start: 20120418
Conference End: 20120421. Conference Publication: (var.pagings). 31 (4
SUPPL. 1) (pp S127), 2012. Date of Publication: April 2012.
Publisher
Elsevier USA
Abstract
Purpose: Testing for reversibility of pulmonary hypertension (PH) is
important for evaluation of candidates for heart transplant. Hemodynamic
effects of multiple drugs used for this purpose were never systematically
analyzed. Our goal is to compare effects of pulmonary vasodilators.
(Figure Presented) Methods and Materials: We identified 20 prospective
studies with documentation of hemodynamic data before and after the
pharmacologic testing for PH reversibility in advanced heart failure.
Effects on pulmonary vascular resistance (PVR) and pulmonary capillary
wedge pressure (PCWP) were analyzed. The data from the studies were pooled
by the drug and weighted on the sample size. Individual drugs were
compared with oxygen as a reference with mixed models using inverse
variance and testing for heterogeneity with random effects. Results: We
had sufficient data for comparison of sodium nitroprusside, milrinone,
nitroglycerine, dobutamine, inhaled nitric oxide, prostaglandin E1,
inhaled prostacyclin, intravenous prostacyclin, and sildenafil. Effects of
different drugs on PVR are shown on Figure 1. Prostaglandins
(prostaglandin E1, and prostacycline, inhaled or intravenous) had the most
potent effect on PVR decreasing it by 2.3, 2.6 and 2.5 Wood units,
respectively. Sildenafil decreased PVR by 1.7 Wood units. In regards to
PCWP, nitroprusside was the most potent drug decreasing it by 14 mm Hg,
followed by nitroglycerin, while prostaglandins did not provide any
significant effect. Conclusions: Because reversibility of pulmonary
hypertension in pretransplant cardiac patients is mostly determined by
vasoconstriction, prostaglandins, especially prostacyclin, appear to be
the drugs of choice in acute reversibility testing.

<17>
Accession Number
70734323
Authors
Hayes K. Leet A.S. Bradley S.J. Holland A.E.
Institution
(Hayes, Leet, Bradley, Holland) Alfred Health, Melbourne, VIC, Australia
(Leet) Baker Heart Institute, Melbourne, Australia
(Holland) La Trobe University, Melbourne, Australia
Title
Effects of exercise training on exercise capacity and quality of life in
patients with a left ventricular assist device (LVAD): A randomised
controlled trial.
Source
Journal of Heart and Lung Transplantation. Conference: 32nd Annual Meeting
and Scientific Sessions of the International Society for Heart and Lung
Transplantation Prague Czech Republic. Conference Start: 20120418
Conference End: 20120421. Conference Publication: (var.pagings). 31 (4
SUPPL. 1) (pp S82), 2012. Date of Publication: April 2012.
Publisher
Elsevier USA
Abstract
Purpose: There is a paucity of studies examining the effect of exercise
training after left ventricular assist device (LVAD) implantation.
Previous research has demonstrated that insertion of the mechanical pump
alone improves exercise capacity and quality of life (QOL). Methods and
Materials: The purpose of this study was to determine whether supervised
exercise training results in a further improvement in exercise capacity
and QOL. Results: A prospective, randomised controlled trial with
concealed allocation, assessor blinding and intention-to-treat analysis
was conducted to investigate the effect of exercise training on exercise
capacity and QOL in 14 patients that underwent LVAD insertion as a bridge
to heart transplantation. Exercise training consisted of eight weeks of
gym-based aerobic and strengthening exercises, in addition to a daily,
progressive mobilisation program, compared to the control group that
completed mobilisation alone. Exercise capacity was measured before and
after intervention using maximal cardiopulmonary exercise testing and six
minute walk distance (6MWD), while QOL was measured using the SF-36.
Conclusions: No adverse events were reported during the trial. There was a
trend towards greater improvement in peak VO&2&, 6MWD and QOL in the
exercise group compared to the control group, however, no significant
between-group difference was detected for improvements in peak VO&2& [Mean
difference (exercise - control) 2.96 ml.kg-1.min-1, 95% CI -1.04 to 6.97],
6MWD [54 m, -51 to 159] and QOL scores over time (p > 0.05). Exercise
training is feasible and safe in patients with a LVAD. Trends toward
greater improvement in exercise capacity and QOL after exercise training
warrant further investigation in a larger trial.

<18>
Accession Number
70734304
Authors
Kaczmarek I. Zaruba M.-M. Sadoni S. Bigdeli A. Schramm R. Meiser B.
Institution
(Kaczmarek, Schramm, Meiser) Transplantation Center,
Ludwig-Maximilians-University, Munich, Germany
(Zaruba) Cardiology, Ludwig-Maximilians-University, Munich, Germany
(Sadoni, Bigdeli) Cardiac Surgery, Ludwig-Maximilians-University, Munich,
Germany
Title
Prospective randomized 3-ARM trial comparing tacrolimus with mycophenolate
mofetil (MMF) or sirolimus with calcineurininhibitor-free
immunosuppression (sirolimus/MMF) after heart transplantation: 5-year
results.
Source
Journal of Heart and Lung Transplantation. Conference: 32nd Annual Meeting
and Scientific Sessions of the International Society for Heart and Lung
Transplantation Prague Czech Republic. Conference Start: 20120418
Conference End: 20120421. Conference Publication: (var.pagings). 31 (4
SUPPL. 1) (pp S76), 2012. Date of Publication: April 2012.
Publisher
Elsevier USA
Abstract
Purpose: Despite improvements in immunosuppression the most advantageous
combination for heart transplant recipients is not established. We
performed a randomized controlled trial to evaluate the efficacy and
safety of three immunosuppressive protocols. Methods and Materials: From
2003 to 2005, 78 cardiac transplant recipients were randomized on a 2:2:1
basis to receive either tacrolimus (TAC) and MMF (n=32), TAC and sirolimus
(SRL) (n=31), or SRL and MMF (n=15). ATG-induction was given in the
SRL/MMF group. Steroids were withdrawn after 6 months. Results: In the
intention to treat analysis 5-year-survival was: 86.1% (TAC/MMF), 93.1%
(TAC/SRL) and 86.7% (SRL/MMF) (p=ns). Freedom from biopsy proven rejection
or hemodynamic compromise rejection at 5 years was 82.4% (TAC/MMF), 85.2%
(TAC/SRL) and 73.3% (SRL/ MMF) (p=ns). Freedom from cardiac allograft
vasculopathy (CAV) was: TAC/MMF 72.2%, TAC/SRL 80.8%, and SRL/MMF 93.3%
revealling superior CAV prevention for SIR/MMF (p=0.01) and TAC/SRL
(p=0.02) when compared to TAC/MMF. Freedom from CMV was: TAC/MMF 72.2%,
TAC/SRL 89.7%, and SRL/MMF 86.7%. There was a superior freedom from CMV
for SRL/ MMF (p=0.01) and TAC/SRL (p=0.01) compared to TAC/MMF. Serum
creatinine at 5 years was TAC/MMF 1.44+/-0.5 mg/dL, TAC/SRL 1.65+/-0.9
mg/dL and SRL/MMF 1.25+/-0.3 mg/dL, revealing a trend towards superior
renal function for SRL/MMF. Cholesterol at 5 years was TAC/MMF 167+/-42
mg/dL, TAC/SRL 179+/-34 mg/dL, and SRL/MMF 183+/-33 mg/dL (p=ns). In the
SRL/MMF group 10 patients temporarily discontinued SRL because of adverse
events or rejection episodes. Conclusions: Both tacrolimus groups proved
to be efficacious for the prevention of acute rejection. The side effect
profile for the SRL/MMF group is inferior to the TAC groups resulting in a
high discontinuation rate. Both sirolimus groups revealed a lower
incidence of CMV infections and cardiac allograft vasculopathy in the
long-term analysis.

<19>
Accession Number
70735525
Authors
Scott N.B.
Title
Future directions for regional anesthesia in fast-track surgery-enhanced
recovery.
Source
Regional Anesthesia and Pain Medicine. Conference: 30th Annual European
Society of Regional Anaesthesia, ESRA Congress 2011 Dresden Germany.
Conference Start: 20110907 Conference End: 20110910. Conference
Publication: (var.pagings). 36 (5 SUPPL. 2) (pp E76-E78), 2011. Date of
Publication: September-October 2011.
Publisher
Lippincott Williams and Wilkins
Abstract
Due to growing economic pressure, the need to reduce hospital lengths of
stay is gaining increasing importance and the transition from fast track
to enhanced recovery programmes embraces this need. Traditional fast track
surgery programmes 'cherry-picked' patients who were young fit and healthy
and by allowing them to deviate from the established routine unit
protocols shorter lengths of stay could be achieved. Enhanced recovery
after surgery (ERAS) is a process that shortens postoperative recovery by
minimising the physical and physiological trauma of the surgery, by
removing non evidencebased traditions and by encouraging early
mobilisation and feeding. ERAS differs from previous 'fast track' and
'accelerated recovery' programmes in that it is not exclusive to the
young, fit and healthy and is not dependent on a patient's suitability for
inclusion. Programmes, if conducted properly, should benefit every
patient. Successful implementation requires the formation of a
multidisciplinary team that focuses on all aspects of the perioperative
period and meets regularly to audit and redesign patient pathways for its
own hospital. This team approach requires leadership that ensures best
practice is achieved by each and every clinical department, similar to the
role of the conductor of an orchestra. Success also depends on the level
of expertise and engagement of the staff involved. Consequently, patients
recover more quickly spend less time in hospital and develop fewer
hospital-associated infections. They are therefore able to return to their
own activities of daily living (ADL) including work, more swiftly. Thus
for the anaesthetist ERAS affords the unique opportunity to convert from
the 'come, stun and run' perception of our 'inferior'specialty to that of
a valued and important member of the perioperative team who can influence
many aspects of the recovery process. Since the mid-1970's, recognition of
'other' benefits of RA on postoperative pathophysiology led to attempts to
define the advantages in comparative 'outcome' studies, but these have
produced less than definitive results, primarily because of the
difficulties associated with such studies even when they are combined by
meta-analysis. Thus there has been some questioning of the place of
regional techniques, especially for the provision of analgesia after major
surgery, driven also by concerns about major complications. However, the
recent Royal College of Anaesthetists UK-wide audit of adverse outcome
after central nerve block has defined such risks more clearly. The
fundamental consideration to achieving the benefits of regional methods
after major surgery is the physiological ('stress') response to surgery.
The changes comprising the response evolved as mechanisms for the repair
of relatively simple injuries, but the scale and range of the responses
after major surgery are anything but beneficial. Convential anaesthetic
and analgesic techniques have minimal effect on these changes, yet
managing (and minimising) their impact is a major component of
peri-operative care, particularly those aspects delivered by
anaesthetists. Regional techniques have much to offer in this area, but
they must be delivered both safely and effectively if the patient is to
benefit. This requires knowledge of the adverse physiological consequences
of surgery, the moderating effects which regional methods can provide, and
an understanding of the ways in which the features of different techniques
may (or may not) contribute to patient safety and comfort. Pain and
analgesia: The pain pathway was long thought to be be a simple conduit to
provide a warning of, and withdrawal from, harmful stimuli, but it is now
recognised that it also has many complex components and functions. General
anaesthesia overcomes what would otherwise be the immediate 'behavioural'
response to surgery, and opioid analgesics provide some relief from the
psychological effects of post-operative pain, but neither has any
significant impact on the physiological processes that the pain pathway
activates. The most immediate of these responses is a reflex increase in
muscle tone ('splinting') to decrease movement and minimise subsequent
pain, but this limits mobilisation after limb surgery and has significant
respiratory impact after abdominal and thoracic procedures. Postoperative
pain reduces both static and dynamic lung parameters, most notably
functional residual capacity and peak flow rate. Basal atelectasis occurs
rapidly, and both deep breathing and effective coughing are impaired.
Secretion retention, airway collapse and venous admixture predispose to
hypoxia, hypercapnia and sepsis, each of which can amplify other aspects
of the stress response. Subsequent changes within the pain pathway itself
can amplify and prolong the pain experienced by the patient, even
resulting in chronic pain states developing. Stimulation of the pain
pathway is also the key to the activation of all other components of the
physiological stress response. The primary aims of analgesia are to
provide/ensure low morbidity and near-immediate mobilization. Thus the
anaesthetic regime should aim to provide a good balance between analgesia
and the patient's ability to mobilise. The growing recognition that the
significant side-effects of all opioids limit the potential for rapid
mobilisation. The concept of 'multimodal analgesia' was designed to
substitute opioids with analgesics that have less troublesome
side-effects, but provide good quality pain relief. The most outstanding
feature of even a single-shot regional technique is the excellent
analgesia (without central depression) that is produced. Pain will develop
on block regression, but administration of supplementary oral or
parenteral analgesics should be timed so that they become effective before
the block wears off. This results in a gradual, rather than a sudden,
awareness of pain and reduces the requirement for (and complications of)
subsequent analgesic therapy. Where needed, catheter techniques allow the
period of profound analgesia to be prolonged well into the postoperative
period. Thus there is Level 1 evidence that the long held and widespread
belief that opioids are the 'gold standard' for postoperative pain is no
longer true. Opioids by whatever route, are inferior to both PNB and CNB
and therefore regional anaesthesia -in all its forms - should remain
central to any ERAS analgesia programme. Sympathetic activation and
sympatholysis: The increased sympathetic activity that follows peripheral
surgery is stimulated mainly by somatic afferent pathways, and is both
minimal and localised, even after lengthy procedures. However, breaching
of the thoracic or abdominal cavities (particularly with handling of the
viscera) produces widespread stimulation of sympathetic afferent pathways,
triggering a multitude of inhibitory reflexes that impair major organ
function as well as releasing adrenal catecholamines and further
interacting with the other cascades. Because the effects are widespread,
block of one or two spinal cord segments is insufficient to prevent these
effects which may persist for several days or even weeks. Regional
techniques produce sympathetic block in the relevant area for the duration
of the block. In peripheral surgery (i.e. of the head, neck and limbs),
afferent somatic and sympathetic block are usually complete, but with the
effects on the circulation being minimal when peripheral blocks are used.
The haemodynamic effects of central blocks used for peripheral surgery are
usually easy to control, with the cause of any significant hypotension
being readily apparent. In body cavity surgery, the consequences of
central techniques are more variable, but there is now considerable
evidence that sympathetic block is effective in reducing the duration and
severity of postoperative systemic organ dysfunction, particularly after
major procedures. However, full knowledge of these effects is needed so
that the patient can be managed appropriately and the benefits gained.
Inflammation and immunosuppression: Current understanding of the
mechanisms that initiate postoperative immunosuppression is poor, but the
magnitude of the stress response correlates directly with both serum
cortisol and the degree of immunosuppression. Triggers include transient
episodes of ischaemia or malperfusion of vulnerable organs or surgical
handling of major vessels and organs. Concomitant complement activation
has been associated with exacerbation of ischaemic brain, kidney and
myocardial injury through increased capillary permeability, neutrophil
activation and protease-activated receptor upregulation. IL-6 produces
negative inotropic effects and myocardial stunning, its concentration
correlating with left ventricular dysfunction and poor clinical outcome,
while IL-8 exacerbates cardiac injury, correlating with cardiac troponin-I
concentrations. In addition, IL-1, IL-6 & IL-8 also promoting the
discharge of A- and C-fibres, further increasing the severity of
postoperative pain. After major surgery both helper and suppressor cells
are suppressed, and the numbers of circulating Natural Killer cells, which
have a wide range of cytotoxic activity particularly against tumour cells,
are reduced also. Thus, cellular immunity is disturbed for up to seven
days postoperatively. Regional compared to general anaesthesia for
transurethral resection of the prostate reduces the postoperative
depression of lymphocyte transformation. Combined spinal and general
anaesthesia was shown to attenuate liver metastasis formation by
preserving Th1/Th2 cytokine balance. These findings suggest that use of
central blocks may result in less immunosuppression, although there is
still relatively little objective evidence to indicate whether such
effects influence outcome.

<20>
Accession Number
70735523
Authors
Moka E. Argyra E. Siafaka I.
Institution
(Moka, Argyra, Siafaka) Greece
Title
Safety of epidural anaesthesia.
Source
Regional Anesthesia and Pain Medicine. Conference: 30th Annual European
Society of Regional Anaesthesia, ESRA Congress 2011 Dresden Germany.
Conference Start: 20110907 Conference End: 20110910. Conference
Publication: (var.pagings). 36 (5 SUPPL. 2) (pp E69-E72), 2011. Date of
Publication: September-October 2011.
Publisher
Lippincott Williams and Wilkins
Abstract
Introduction: Every patient wishes to receive anaesthesia care that is
safe, in other words, free from risk, not involving danger or mishap and
guaranteed against failure. Anaesthesiologists usually present a more
realistic view to the patient. The personal view of the hoped-for care
will be one in which the clinical outcome is satisfactory and achieved
without complications, since performance has not deviated from the ideal.
By this standard, most deviations are trivial or easily corrected by a
perfect process, whereas patient outcome and a reasonably stress-free life
for the clinician are objectives for all anaesthesiologists [1]. Safety of
an anaesthetic technique is characterized by avoidance of complications,
minimal percentages of associated risks and numerous primary and secondary
beneficial endpoints, balanced against the inevitable consequences of
method-related dangers. Consequently, prior to any conclusion regarding
safety, reliable evidence must be established for both sides of the
anaesthetic technique benefit-and-risk equation [2, 3]. Epidural
anaesthesia-analgesia (EAA) has a long and distinguished history. For many
clinicians, it remains an attractive option and a leading anaesthetic-
analgesic modality applied in the perioperative environment [4, 5]. In
regard to the benefit side, there is widespread conviction among
anaesthesiologists that EAA offers significant advantages in certain
settings, especially those involving abdominal and thoracic operative
procedures [4, 6]. EAA is highly effective for controlling acute pain
after surgery or trauma to the chest, abdomen, pelvis or lower limbs, with
its salutary effects providing an added therapeutic benefit
postoperatively. It has been instituted in various subpopulations,
including cardiothoracic, vascular, paediatric and obstetric patients,
with optimistic and promising results. Usually, the combination of
excellent pain relief, associated with minimal side-effects, results in
high patient satisfaction, when compared with other methods of analgesia
[4, 6-8]. However, the controversy around EAA still continues,
particularly with regard to its true impact on postoperative morbidity and
mortality, as well as its safety, mostly due to the fear of rare, but
potentially life-threatening or catastrophic complications [3, 6, 9].
Controversies represent the debate and dialogue that ensue when clinicians
examine the issue of best practice. Taking into account the other
("darker?") side of the benefit-and-risk equation, unfortunately, the fear
of complications is still held with almost equal intensity, compared to
the enthusiasm which initially escorts EAA beneficial effects. Since there
is always risk attached to all anaesthesia methods, contemporary EAA
practice in certain situations has been controversial. In addition, the
main factor which in the past turned our specialty away from EAA has been
the difficulty in making a reasonable risk/benefit analysis about the
technique, resulting in clinicians constantly asking whether epidurals are
effective and whether the technique can finally be safe [2-4, 6, 9-12].
Nowadays, EAA is widely used again and since it is an invasive method, its
benefit/risk ratio deserves to be appraised, in order to help physicians
estimate technique safety, make appropriate choice among other
opportunities (general anaesthesia, peripheral nerve blocks, wound
infiltration) and provide objective information to patients, prior to
their written informed consent acquisition [5, 6, 13]. In this context,
the "ultimate tool" of evidencebased medicine, the Level 1 evidence of
meta-analysis, has shown over the previous years that EAA decreases
postoperative morbidity and mortality [6, 15], as well as pulmonary
complications [16], improves bowel recovery [17] and reduces incidence of
myocardial infarctions [18]. However, evidence to support improved outcome
from surgery remains elusive [19, 20], with the exception of aortic
surgery, where mortality and major complications were significantly
reduced [21]. Therefore, it is not surprising that research and more or
less scientific and emotive debates in this area continue, even more so in
view of reports of safety, complications and the current medicolegal
environment in many countries [5, 6]. EAA complications have been
described by many authors, although our understanding of the numerous risk
factors is limited [2, 10-14]. Despite their relatively infrequent
occurrence, the fear of EAA complications exceeds their actual incidence
[2, 3, 9, 13, 22]. Incidence knowledge could be an essential component of
the clinical decision-making, objective safety judging and consent
processes, although there are few good and detailed data, which can be
quoted to support such discussions, leaving both patient and clinicians in
quandary. Figures (ranging from 1:1.000 to 1:100.000 in general) are
quoted, but their doubtful validity questions the ability to obtain
genuinely informed consent from patients offered these procedures [13].
Although it is impossible to prevent all EAA complications, it may be
possible to reduce their occurrence, by avoiding well-defined risk factors
and by using a meticulous epidural technique at all times. Further studies
on clarification of risks, complications' early recognition and on EAA
technique improvement may reduce adverse effects occurrence and improve
EAA safety [13, 14, 22]. In the following paragraphs, the general
objective is to focus on the clinical aspects of EAA risks in terms of
their incidence, recognition, prevention and management, in an effort to
provide information that will help clinicians to avoid or minimize
complications, incurred during technique application. In this context, EAA
provision can be safe, as well as effective, if described risks and
benefits are carefully considered and the Hippocratic axiom "primum non
nocere" is kept in mind. Complications and Safety of EAA: Aetiology -
Evaluation of Evidence EAA complications represent the unexpected or
untoward events following the application of the technique itself or the
exposure to anaesthetic agents. They can be classified as simple adverse
events and common or uncommon/rare complications. Some of them are
considered minor side effects, easy to prevent and to manage, that usually
do not raise safety concerns. However, others, resulting from EAA as
unexpected outcomes, are of major concern, due to their potential to cause
neurological damage, leading to long-term or permanent disability. Both
major and minor EAA complications are well-known to clinicians and are
also well-annotated. They can occur immediately, or can be delayed. They
can be clinically insignificant, or, in rare situations, life-threatening.
Knowledge and attention to the technique can reduce the likelihood for
major complications. The impact of EAA complications in anaesthesia
practice is significant because anaesthesia care is rarely therapeutic and
known to carry risks. Furthermore, there is compelling evidence that
adverse outcomes trigger malpractice claims. As a group,
anaesthesiologists seem to accept the blame of complications that may or
may not have been caused by EAA itself. Furthermore, even when the
standard of care has been met, juries tend to assign blame more readily in
EAA complicated cases [2, 9-14, 22]. EAA complications [2, 6, 9-12, 22],
may happen in the whole perioperative period, including the postoperative
one and can be the direct or indirect result of the following: - the
technique itself: usually related to direct or indirect trauma by needle/
catheter insertion and/or catheter presence in the epidural space - the
untoward effects of local anaesthetics/adjuvant drugs instilled - local
and systemic toxicity results of drugs infused - fatal drug errors -
untoward effects resulting from the anticipated or unanticipated
physiologic consequences of local anaesthetic blockade - poor/late/no
management of physiologic responses and/or adverse effects (arterial
hypotension-fatal cardiovascular collapse) - intraoperative technical
problems/equipment failure - ignorance regarding complications'
anticipation/recognition of precipitating factors - delayed complications'
diagnosis - non-application/delayed application of complications'
preventive measures - lack of experience/education/audit/monitoring -
human/behavioural/operator/patient factors EAA complications have been
recognized over 100 years ago and the database concerning such risks is
large but confusing. Studies are scarce, and their results difficult to
compare. Due to their rarity, definite studies on EAA risks remain
problematic and the quoted ranges of complications for severe adverse
events still vary widely, because the study methodologies vary, much of
the data are retrospective, and the distinction between permanent and
temporary disability is not always clear. Many complications are known
through case reports, and these rare events might not be evenly
distributed within the patient population. Retrospective observational
studies/surveys and case reports are important sources for evaluation,
providing valuable information on incidence and possible associations with
confounding factors. Observational data are often clinically relevant, can
have a profound influence on clinical practice when a consensus of
opinions is formulated, but, unlike randomized controlled trials, lack a
control group, making it difficult to calculate an accurate incidence of
risk. Because the enormous number of patients needed to perform
prospective studies exceeds feasibility, it is important that
retrospective studies try to minimize the inherent weakness of such study
designs. Underreporting is common in retrospective studies, causing
underestimation of risk [2, 3, 6, 9, 10, 14, 22].

<21>
Accession Number
70735517
Authors
Gottschalk A.
Institution
(Gottschalk) Germany
Title
Regional anaesthesia and organ protection.
Source
Regional Anesthesia and Pain Medicine. Conference: 30th Annual European
Society of Regional Anaesthesia, ESRA Congress 2011 Dresden Germany.
Conference Start: 20110907 Conference End: 20110910. Conference
Publication: (var.pagings). 36 (5 SUPPL. 2) (pp E63-E64), 2011. Date of
Publication: September-October 2011.
Publisher
Lippincott Williams and Wilkins
Abstract
Regional anaesthesia - epidural anaesthesia as well as peripheral nerve
blocks - has been shown to provide superior analgesia compared to other
analgesic regimes [2, 6]. Additionally now the question arises which
effects regional anaesthesia has with respect to organ protection and long
term outcome of patients after surgery. However, whereas several studies
have been published evaluating the effects of epidural anaesthesia on
organ protection no sufficient evidence exists concerning organ protective
effects of peripheral nerve blocks. Studies concerning organ protective
effects have been performed with respect to the cardiac, pulmonary and
gastrointestinal system. Experimental studies were able to show that
thoracic epidural anaesthesia is able to reduce the activation of the
sympathetic nerve system [8]. This effect may reduce the postoperative
stress response as well as the activation of the coagulation system.
Thoracic epidural analgesia has been shown to reduce the incidence of
myocardial infarction in patients undergoing vascular surgery [1]. Singh
et al were able to show that epidural analgesia in patients undergoing
infrainguinal vascular surgery is able to reduce the incidence of
cardiovascular, respiratory and gastrointestinal complications and
myocardial infarction [9]. Results after coronary bypass surgery are
inconsistent. Thoracic and abdominal surgery results in a relevant
impairment of pulmonary function [10. Several studies were able to show
that thoracic epidural analgesia is able to reduce postoperative pulmonary
complications like atelectasis and pneumonia, and is able to improve lung
function and oxygenation. Protective effects of epidural anaesthesia with
respect to the development of pneumonia have been shown recently [5].
Additionally duration of postoperative ventilation and need of
reintubation were reduced, lung function and oxygenation could be
improved. Concerning the gastrointestinal system use of epidural
anaesthesia results in a reduced duration of postoperative ileus and
gastrointestinal dysfunction especially after abdominal surgery and
improves oral intake [3]. These positive effects of epidural anaesthesia
are a milestone in the development of "fast-track-surgery" concepts. No
effects of regional anaesthesia on postoperative cognitive dysfunction has
been detected by now [4]. Due to methological problems the evaluation of
the influence of regional anaesthesia on mortality rates after surgery is
difficult to perform as a huge number of patients is necessary to include.
Until today meta-analyses and retrospective analyses have been published
demonstrating a slight reduction in mortality rate [7, 11, 12]. These
results should be interpreted with extreme caution as the differences are
quite small and prospective randomised studies are still missing. Thoracic
epidural anaesthesia has been shown to improve cardiac, pulmonary and
gastrointestinal function. These effects should be used intensively in
multimodal concepts to improve patients' outcome. Results concerning
influences of epidural anaesthesia on mortality rates remain inconsistent.

<22>
Accession Number
70735488
Authors
Missant C.
Institution
(Missant) Belgium
Title
Regional anesthesia for awake cardiac surgery.
Source
Regional Anesthesia and Pain Medicine. Conference: 30th Annual European
Society of Regional Anaesthesia, ESRA Congress 2011 Dresden Germany.
Conference Start: 20110907 Conference End: 20110910. Conference
Publication: (var.pagings). 36 (5 SUPPL. 2) (pp E27-E28), 2011. Date of
Publication: September-October 2011.
Publisher
Lippincott Williams and Wilkins
Abstract
Regional anesthesia for cardiac surgery: Escalating costs and changing
profiles of cardiac surgery patients requires continuous modification of
perioperative management strategies. Regional anesthesia plays a role in
many fast track anesthesia protocols, including anesthesia for cardiac
surgery. Regional anesthesia techniques for cardiac surgery include
continuous local anesthetic infiltration, intrapleural local anesthetics,
intercostal and paravertebral nerve blocks and intrathecal/epidural
techniques. Although appropriate studies are lacking, it is assumed that,
compared to intravenous opioids, only intrathecal and epidural anesthesia
provide equipotent analgesia. In addition to excellent analgesia and a
reduction in respiratory complications, thoracic epidural anesthesia (TEA)
induced sympathicolysis improves the endogenous stress response, and
reduces the myocardial oxygen demand and infarct size. The use of TEA in
cardiac surgery, however, remains controversial because the insertion of
an epidural catheter in patients requiring full heparinization may lead to
an epidural hematoma and permanent neurological injury if not detected and
evacuated promptly. In addition, TEA induced sympathicolysis has recently
been shown to decrease left ventricular contractility and to abolish the
positive inotropic response of the right ventricle to an acute increase in
afterload(1-2). The use of TEA in cardiac surgery has regained new
interest in the last two years. A number of randomized controlled trials
and meta-analyses have been published recently. Last year, Bignami et al.
published a meta-analysis including 2366 patients. They concluded that
epidural analgesia improved outcome after cardiac surgery, indicated by
reduced incidence of acute renal failure, time on mechanical ventilation
and a reduction in the composite endpoint mortality/infarction(3). In
2011, Svircevic et al. subsequently have reported a randomized controlled
trial in 654 elective cardiac surgical patients who were randomized to
combined general anesthesia (GA) and TEA versus GA. Thirty day and 1-year
survival free from myocardial infarction, pulmonary complications, renal
failure and stroke were not different in both regimens (4). A metaanalysis
investigating the effects of adding a TEA to general anesthesia for
cardiac surgery, including a total of 28 randomized controlled trials with
a total of 2700 patients concluded that the addition of a TEA reduced the
incidence of supraventricular arrhythmias and respiratory complications
but had no effect on mortality, myocardial infarction or stroke(5).
Specifically in patients undergoing OPCAB surgery, Caputo et al showed
that the addition of TEA to GA reduces the incidence of postoperative
arrhythmias and improves pain control and overall quality of recovery,
allowing earlier extubation and hospital discharge(6). In conclusion, the
addition of TEA to GA for cardiac surgery enhances postoperative analgesia
and reduces postoperative ventilation times but is labour intensive and
has a high clinical risk and failure rate without a clear effect on
clinical outcome. The actual and potential risks and benefits of a TEA
during cardiac surgery should be taken into account for every individual
patient. Awake cardiac surgery: Awake cardiac surgery with the use of only
TEA has been suggested as an alternative to GA for both low and high risk
on- and off pump procedures via lower or full median sternotomy or minimal
invasive approaches using a small thoracotomy. Several manuscripts have
already reported awake cardiac surgery to be safe and feasible if all
preventive measures and international guidelines are taken into account to
avoid epidural hematoma. Conversion rates to GA have been reported between
0 and 10% due to inadequate analgesia or respiratory difficulties. Besides
a growing number of case reports, few studies have compared anesthesia
techniques including sole TEA for cardiac surgery (mainly due to ethical
and medical considerations). In addition, few data are available on
postoperative outcomes after awake cardiac surgery. In 2005, Kessler et al
have compared GA with combined GA and TEA and sole TEA for OPCAB surgery.
They reported all anesthetic techniques to be equally safe, but the
combination GA + TEA appeared to be most comprehensive (7). A comparable
study by Porizak et al in 2011 found all three anesthetic methods
equivalent in terms of early and late postoperative outcome (including
3-year mortality) except for a lower incidence of atrial fibrillation in
the awake TEA group (8). Very recently, Watanabe et al reported a
favourable surgical outcome and postoperative recovery after day case
awake off-pump cardiac surgery in 72 patients with severe pre-operative
comorbidities, including cerebrovascular impairment or severe pulmonary
disease (9). Conclusion: A final ranking of available anesthesia
techniques for cardiac surgery remains difficult. General anesthesia
without TEA is the established technique and should be used whenever
contraindications for epidural catheters apply. The decision which
technique is used in an individual patient should be made on an individual
basis regarding both the patient and the anesthesiologist's personal
preference. Although it is the author's opinion that systemic
anticoagulation hampers the use of epidural techniques, it is not
unimaginable that for few patients, GA+TEA and even sole TEA may be
preferred.

<23>
Accession Number
70733402
Authors
Glantz H. Thunstrom E. Herlitz J. Cederin B. Kallryd A. Ejdeback J. Peker
Y.
Institution
(Glantz) Dept. of Internal Medicine, Skaraborg Hospital, Lidkoping, Sweden
(Glantz, Thunstrom, Peker) Dept. of Emergency and Cardiovascular Medicine,
Sahlgrenska Academy, University of Gothenburg, Sweden
(Herlitz) Dept. of Cardiology, Sahlgrenska University Hospital,
Gothenburg, Sweden
(Cederin) Dept. of Internal Medicine, Skaraborg Hospital, Skovde, Sweden
(Kallryd, Ejdeback) Dept. of Cardiology, Skaraborg Hospital, Skovde,
Sweden
(Peker) Dept. Neurology, Rehabilitation and Sleep Medicine, Skaraborg
Hospital, Skovde, Sweden
Title
Occurence of obstructive sleep apnea in revascularized patients with
coronary artery disease: Baseline clinical characteristics of the RICCADSA
trial.
Source
Scandinavian Cardiovascular Journal. Conference: 14th Svenska
Kardiovaskulara Varmotet Stockholm Sweden. Conference Start: 20120425
Conference End: 20120427. Conference Publication: (var.pagings). 46 (pp
26), 2012. Date of Publication: June 2012.
Publisher
Informa Healthcare
Abstract
Background: The RICCADSA study is an on-going, randomized, controlled
trial in Skaraborg County, Western Sweden, addressing the impact of
continuous positive airway pressure (CPAP) on cardiovascular outcomes in
patients with coronary artery disease (CAD) and obstructive sleep apnea
(OSA). In this cross-sectional analysis, we describe the occurrence of OSA
and clinical characteristics of the cohort. Material and methods: All
patients undergoing Percutaneous Coronary Intervention or Coronary Artery
Bypass Grafting between September 2005 and November 2010 (n = 1291) were
invited to participate. Anthropometrics, medical history and sleep data
were recorded and all subjects completed Epworth Sleepiness Scale (ESS)
questionnaire. In total, 662 patients agreed and underwent an ambulatory
polygraphic sleep recording. OSA was defined as an Apnea-Hypopnea-Index
(AHI) > 15/h. Results: OSA was found among 422 (63.8%) patients. The
prevalence of hypertension was 55.9%, obesity (Body-Mass-Index > 30 kg/m2)
25.2%, diabetes mellitus 22.1% and current smoking 18.9%. The majority
(62.1%) of the OSA patients were non-sleepy (ESS score < 10). Age, male
gender and obesity were associated with OSA independently of the other
comorbidities. Within the OSA group, there were no significant clinical
differences among the non-sleepy subjects, except for less obesity.
Conclusions: Among revascularized CAD patients, OSA was more prevalent
than other traditional risk indicators, suggesting that OSA should be
considered as a confounding factor in the current secondary prevention
protocols. Whether or not all CAD patients with OSA should be treated by
CPAP, regardless of daytime sleepiness, needs to be further clarified.