[Show abstract][Hide abstract] ABSTRACT: The aims of this study were first to analyze neurocognitive outcomes of patients after open-chamber cardiac surgery to determine whether carbon dioxide pericardial insufflation reduces incidence of neurocognitive decline (primary end point) as measured 6 weeks postoperatively and second to assess the utility of carbon dioxide insufflation in cardiac chamber deairing as assessed by transesophageal echocardiography.
A multicenter, prospective, double-blind, randomized, controlled trial compared neurocognitive outcomes in patients undergoing open-chamber (left-sided) cardiac surgery who were assigned carbon dioxide insufflation or placebo (control group) in addition to standardized mechanical deairing maneuvers.
One hundred twenty-five patients underwent surgery and were randomly allocated. Neurocognitive testing showed no clinically significant differences in z scores between preoperative and postoperative testing. Linear regression was used to identify factors associated with neurocognitive decline. Factors most strongly associated with neurocognitive decline were hypercholesterolemia, aortic atheroma grade, and coronary artery disease. There was significantly more intracardiac gas noted on intraoperative transesophageal echocardiography in all cardiac chambers (left atrium, left ventricle, and aorta) at all measured times (after crossclamp removal, during weaning from cardiopulmonary bypass, and at declaration of adequate deairing by the anesthetist) in the control group than in the carbon dioxide group (P < .04). Deairing time was also significantly longer in the control group (12 minutes [interquartile range, 9-18] versus 9 minutes [interquartile range, 7-14 minutes]; P = .002).
Carbon dioxide pericardial insufflation in open-chamber cardiac surgery does not affect postoperative neurocognitive decline. The most important factor is atheromatous vascular disease.
The Journal of thoracic and cardiovascular surgery 05/2012; 144(3):646-653.e1. · 3.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: With the recent withdrawal of the antifibrinolytic aprotinin from the market, tranexamic acid (TxA) has become more widely used. This change has led to increasing concern about the side-effect profile of TxA, particularly the incidence of postoperative seizures. In this case series, we describe 7 patients over an 18-month period who had open-chamber cardiac surgery and developed seizures in the postoperative period. This incidence is increased compared with that of a cohort of patients in the previous 36 months who did not receive TxA (0.66% versus 0%; P < .05). The exact mechanism of TxA-induced seizures is thought to be via inhibition of gamma-aminobutyric acid receptors in neurons. Data from the neurosurgical literature show a well-established link between this antifibrinolytic and seizures. There is now increasing awareness of this association in cardiac surgery, particularly when high TxA doses are used.
Heart Surgery Forum 08/2010; 13(4):E257-9. · 0.63 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A pain syndrome related to intercostal nerve injury during internal thoracic artery harvesting causes significant morbidity after coronary bypass surgery. We hypothesized that its incidence and severity might be reduced by using skeletonized internal thoracic artery harvesting rather than pedicled harvesting.
In a prospective double-blind clinical trial, 41 patients undergoing coronary bypass were randomized to receive either unilateral pedicled or skeletonized internal thoracic artery harvesting. Patients were assessed 7 (early) and 21 (late) weeks postoperatively with reproducible sensory stimuli used to detect chest wall sensory deficits (dysesthesia) and with a pain questionnaire used to assess neuropathic pain.
At 7 weeks postoperatively, the area of harvest dysesthesia (percentage of the chest) in the skeletonized group (n = 21) was less (median, 0%; interquartile range, 0-0) than in the pedicled group (n = 20) (2.8% [0-13], P = .005). The incidence of harvest dysesthesia at 7 weeks was 14% in the skeletonized group versus 50% in the pedicled group (P = .02). These differences were not sustained at 21 weeks, as the median area of harvest dysesthesia in both groups was 0% (P = .89) and the incidence was 24% and 25% in the skeletonized and pedicled groups, respectively (P = 1.0). The incidence of neuropathic pain in the skeletonized group compared with the pedicled group was 5% versus 10% (P = .6) at 7 weeks and 0% versus 0% (P = 1.0) at 21 weeks.
Compared with pedicled harvesting, skeletonized harvesting of the internal thoracic artery provides a short-term reduction in the extent and incidence of chest wall dysesthesia after coronary bypass, consistent with reduced intercostal nerve injury and therefore the reduced potential for neuropathic chest pain.
The Journal of thoracic and cardiovascular surgery 09/2009; 139(3):674-9. · 3.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although concomitant coronary bypass, and mitral and tricuspid valve surgery have been used to expand the donor pool for cardiac transplantation, aortic valve disease is considered an absolute contraindication for use of an offered organ. A case is presented with the successful use of an organ requiring concomitant aortic valve replacement for calcific aortic stenosis on a congenitally bicuspid valve. Eighteen-month follow-up documented excellent allograft function with a normally functioning mechanical aortic prosthesis. Aortic valve disease in offered organs can be successfully treated with aortic valve replacement at the time of transplantation and should not preclude the use of the organ in the setting of a recipient who is a candidate for a marginal allograft.
The Annals of thoracic surgery 01/2009; 86(6):1979-82. · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is an increasing requirement for lung re-transplants (re-LTx) related to the bronchiolitis obliterans syndrome. Nevertheless, re-LTx, especially second-time re-LTx, poses the dilemma of appropriate allocation of a scarce donor lung resource versus the desire to optimize outcomes for an individual patient. Extended donors have been used to partially alleviate a scarce donor lung supply with satisfactory outcomes for primary lung transplant. However, the usefulness of the extended donors remains unknown, including donation-after-cardiac-death donors for re-LTx. This report describes a second-time re-LTx using significantly extended donor criteria lungs from a Maastricht category IV donation-after-cardiac-death donor with resultant good clinical outcomes.
The Annals of thoracic surgery 09/2007; 84(2):642-4. · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In response to the current state of healthcare in Australia, our unit has employed a fast-track policy for low-risk cardiac surgery patients since January 2000. This study was designed to examine the safety and efficacy of this policy. From July 2001 to June 2004, 342 (23%) of 1,488 patients undergoing cardiac surgery were identified preoperatively as suitable for fast-track recovery. There was a significantly shorter median time to extubation (4 hr vs 9 hr), reduced intensive care unit stay (8 hr vs 26 hr), and a lower rate of readmission to the intensive care unit (0.6% vs 4.2%) for those fast tracked compared to the other patients. The fast-track group had a lower incidence of complications and significantly decreased median length of hospital stay (5 vs 7 days). We concluded that this policy accurately identifies the low-risk cardiac surgery patients suitable for less intensive postoperative recovery.
Asian cardiovascular & thoracic annals 05/2007; 15(2):139-43.
[Show abstract][Hide abstract] ABSTRACT: The aim of this paper was to review the outcomes of cardiac transplantation with regards to short- and long-term survival, focusing particularly on patients who receive organs with long ischemic times and the resource utilization necessary to support such patients through their postoperative period.
A retrospective review of 420 consecutive cardiac transplants in a single institution was undertaken.
The five- and 10-yr survival rates for the entire group were 0.76 (95% CI: 0.72-0.80) and 0.60 (0.54-0.66). There was no decrease in mid- or long-term survival in patients who received organs with ischemic times over 300 min. Longer donor organ ischemic time was not associated with increased 30 d mortality but was significantly associated with longer intensive care bed stay, increased incidence of primary graft failure, need for mechanical support, and complications such as acute renal failures.
Although using donor organs with longer ischemic times for cardiac transplantation does not impact on survival, there is a significantly increased utilization of resources to ensure these patients survive the postoperative period.
[Show abstract][Hide abstract] ABSTRACT: Cardiac surgery represents major metabolic, physical and mental stresses associated with an increased production of reactive oxygen species. These stresses may hamper post-operative recovery, increasing hospitalisation times and operative mortality. We conducted a quality assurance and feasibility study to evaluate and monitor the safety and efficacy of a new program of combined pre-operative metabolic (enhanced antioxidant), physical and mental therapy to counter these stresses prior to cardiac surgery.
Sixteen cardiac surgery patients received metabolic therapy consisting of the antioxidants coenzyme Q(10) (CoQ(10)) (300 mg) and alpha-lipoic acid (300 mg), combined with magnesium orotate (1200 mg), and omega-3 fatty acids (3g) given daily for a mean 36+/-7 days up until the day of operation. Patients also received a regimen of physical therapy incorporating non-exhaustive, light exercise and stretching techniques. Mental therapy in the form of stress reduction, relaxation and music was also provided. Blood levels of CoQ(10) and malondialdehyde (MDA) were measured and a quality of life (QoL) questionnaire (SF-36) was administered before, after the program and 1 month after surgery. A patient satisfaction survey was conducted at six weeks post-operatively.
During the pre-operative period, treated patients (n=16) showed significant improvements in QoL composite scores, physical (33.5+/-4.1 to 41.0+/-4.5, p=0.005) and mental (44.3+/-4.5 to 54.1+/-5.3, p=0.006). CoQ(10) levels increased from 725.6+/-96.1 nmol/l to 3019.9+/-546.4 nmol/l (p=0.006), MDA levels decreased from 2.2+/-0.9 microM to 1.4+/-0.7 microM (p=0.013) and systolic blood pressure decreased from 140+/-4.0 mmHg to 132+/-3.0 mmHg (p=0.002). One month after surgery the treated group (n=14) demonstrated significant improvements from pre-operative baseline in QoL composite scores, physical (38.9+/-4.0 to 57.9+/-5.4, p=0.01) and mental (50.3+/-5.6 to 69.3+/-4.8, p=0.03) compared to a previously reported similar group of cardiac surgery patients (n=74) whose physical and mental scores decreased from 43.0 to 42.8 (p=0.05) and 53.8 to 49.8, respectively (p=0.05).
These preliminary results suggest that a program of combined metabolic, physical and mental preparation before cardiac surgery is safe, feasible and may improve quality of life, lower systolic blood pressure, reduce levels of oxidative stress and thus has the potential to enhance post-operative recovery.
[Show abstract][Hide abstract] ABSTRACT: There is an important role for accurate risk prediction models in current cardiac surgical practice. Such models enable benchmarking and allow surgeons and institutions to compare outcomes in a meaningful way. They can also be useful in the areas of surgical decision-making, preoperative informed consent, quality assurance and healthcare management. The aim of this study was to assess the performance of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) model on the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) patient database.
The additive and logistic EuroSCORE models were applied to all patients undergoing cardiac surgery at six institutions in the state of Victoria between 1st July 2001 and 4th July 2005 within the ASCTS database who have complete data. The entire cohort and a subgroup of patients undergoing coronary artery bypass grafting (CABG) only were analysed. Observed and predicted mortalities were compared. Model discrimination was tested by determining the area under the receiver operating characteristic (ROC) curve. Model calibration was tested by the Hosmer-Lemeshow chi-square test.
Eight thousand three hundred and thirty-one patients with complete data were analysed. There were significant differences in the prevalence of risk factors between the ASCTS and European cardiac surgical populations. Observed mortality was 3.20% overall and 2.00% for the CABG only group. The EuroSCORE models over estimated mortality (entire cohort: additive predicted 5.31%, logistic predicted 8.76%; CABG only: additive predicted 4.25%, logistic predicted 6.19%). Discriminative power of both models was very good. Area under ROC curve was 0.83 overall and 0.82 for the CABG only group. Calibration of both models was poor as mortality was over predicted at nearly all risk deciles. Hosmer-Lemeshow chi-square test returned P-values less than 0.05.
The additive and logistic EuroSCORE does not accurately predict outcomes in this group of cardiac surgery patients from six Australian institutions. Hence, the use of the EuroSCORE models for risk prediction may not be appropriate in Australia. A model, which accurately predicts outcomes in Australian cardiac surgical patients, is required.
European Journal of Cardio-Thoracic Surgery 05/2006; 29(4):441-6; discussion 446. · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: An inadequate donor left atrial (LA) cuff due to an anatomical abnormality of the pulmonary vasculature or technical errors at the time of procurement can exclude the lungs from transplant. This study aims to describe the incidence, efficacy, and various techniques of LA cuff reconstruction in lung transplantation.
A total of 637 pulmonary venous anastomosis in 405 consecutive lung transplants from January 1995 to July 2005 were reviewed. Comparison between the patients who required LA cuff reconstruction (reconstruction group) or who did not (no-reconstruction group) was made in posttransplant outcomes.
An overall incidence of requirement of LA cuff reconstruction was 2.7% (4% on the right, 1% on the left, p = 0.03). Seventy-one percent of LA inadequacy was corrected using a pericardial patch on the anterior LA cuff wall; the remainder required complicated reconstruction for separated/short pulmonary veins to create a new LA cuff. There was no significant difference between the reconstruction and no-reconstruction groups, respectively, in oxygenation (329 +/- 28, 337 +/- 10, p = 0.81), duration of intubation and intensive care unit stay (p = 0.54, p = 0.89, respectively), 30-day mortality (12%, 6%, p = 0.30), and 5-year survival (57%, 52%, p = 0.80).
Inadequate donor LA cuff is an infrequent but potentially serious complication in lung transplantation. Donor LA cuff reconstruction using donor pericardium or pulmonary artery remnant is a useful technique to salvage surgically marginal lungs without affecting early and late posttransplant outcomes. These lungs should not be excluded from transplantation.
The Annals of thoracic surgery 05/2006; 81(4):1199-204. · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Primary graft failure (PGF) is the leading cause of early mortality after cardiac transplantation, accounting for 27.1% of deaths within 30 days. PGF is defined as severe dysfunction of the cardiac allograft without any obvious anatomic or immunological cause. The purpose of this study was to analyze our last 9 years of experience with cardiac transplantation to determine predictors of PGF and the influence on survival of our policy of early institution of mechanical circulatory support (MCS) in these patients.
Data on 214 consecutive cardiac transplants performed at The Alfred Hospital between January 1996 and August 2004 were reviewed. PGF was defined as right or left or biventricular failure manifesting as hypotension (systolic blood pressure <90 mm Hg), low cardiac output (cardiac index <2.0 liter/min/m2 and pulmonary capillary wedge pressure >20 mm Hg after coming off cardiopulmonary bypass despite inotropic support of up to 5 mug/min adrenaline and without any other obvious cause for the graft dysfunction.
PGF developed in 51 patients (24%). Significant factors in the development of PGF were long ischemic time, which became significant over 4 hours (odds ratio, 1.43; p = 0.01) and increased donor age (odds ratio, 1.027; p = 0.045). Fifteen patients required mechanical support, and of these, 10 survived to leave hospital.
PGF is the major cause of early mortality after cardiac transplantation. Significant risks for PGF are long allograft ischemic time and increased donor age. Once the patient has survived 30 days, however, the longer-term survival is not influenced by PGF. Our management strategy of early mechanical support has yielded good outcomes in this population with a high risk of early death.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 01/2006; 24(12):2037-42. · 3.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The VentrAssist device left ventricular assist system, designed for permanent implantation, is a novel centrifugal pump with a hydrodynamically suspended rotor. The first human implant was into a 72-year-old man with New York Heart Association (NYHA) class IV heart failure due to idiopathic dilated cardiomyopathy. The implant and recovery were uneventful, and the patient survives at 17 months, is NYHA class II, and lives at home. This device shows promise in end-stage heart failure for permanent implantation and bridge to transplantation.
The Journal of Heart and Lung Transplantation 09/2005; 24(8):1150-4. · 5.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Severe pulmonary graft failure (PGF) is the most common cause of death within the first 30 days after lung transplantation. Extracorporeal membrane oxygenation (ECMO) may provide lifesaving temporary support; however, its longer-term efficacy is controversial.
We reviewed the use of ECMO for severe PGF after lung transplantation, and compared the outcomes between our early (1990 to 1999) and recent (2000 to 2003) experience utilizing improved initiation timing, oxygenator technology, and surgical technique.
Ten transplant recipients from a total of 481 (2.1%) were managed for PGF on ECMO by a multidisciplinary team at The Alfred Hospital. Four single-lung, 3 bilateral single-lung, and 3 heart-lung recipients were supported for a mean of 96 hours (range 14 to 212 hours). In the early group (operation from 1990 to 1999, n = 4) ECMO was initiated 21 days (range 7 to 40 days) after lung transplantation and in the recent group (operation from 2000 to 2003, n = 6) after 0 to 2 days (p = 0.01). Radial-arterial blood gas analysis 12 hours after initiation of ECMO showed significantly better oxygenation in the recent group (341 +/- 90 mm Hg) than in the early group (90 +/- 23 mm Hg, p = 0.03). Four deaths occurred as a result of bleeding (two in each group). In the early group only 1 patient was weaned from ECMO but died. In the recent group 3 were successfully weaned and were discharged from the intensive care unit; of these patients, 2 were discharged from hospital.
Extracorporeal membrane oxygenation results have improved with advances in oxygenator technology and surgical techniques. The procedure can allow resolution of early PGF after lung transplantation.
The Annals of thoracic surgery 11/2004; 78(4):1230-5. · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) have established a database for the collection and analysis of the results of cardiac surgery in Australia and New Zealand. Initially data has been collected only in Victoria public hospitals. This report covers the first 12 months of data collection from 1st August 2001 to 1st July 2002.
Whilst cardiac surgical performance in Australia is considered to be of a high standard equivalent to other developed countries, there is currently no systematic approach to data collection in order to provide performance indicators and benchmarks. The development of an Australasian cardiac surgical database and performance indicators will enable benchmarking and comparison with international standards which should lead to performance improvements.
A database definition set and standardised data collection form was developed by the ASCTS for all participating cardiac surgery units in public hospitals in Victoria. Opt-off consent for subject inclusion in the database was approved by each participating institutional ethics review committee. An electronic database and reporting application was developed. Data included in this analysis is from the initial 12 months collection from all hospitals participating in the project from 1st August 2001 to 31st July 2002.
Overall, there were 2982 procedures performed in this period of which 2969 had sufficient data to be included in this analysis (99.5%). The majority of procedures 2017 (68%) being undertaken were isolated coronary artery bypass surgery (CABG). The mean age of all subjects undergoing procedures was 65 years (range: 18-91 years) and 70% were male. 64% of all procedures were elective and 6.1% emergency or salvage. Median post-procedure length of hospital stay for all procedures was 6.0 days and intensive care unit (ICU) stay was 23.0h. Re-operation for haemorrhage occurred in 2.1% of all cases and deep sternal infection in 0.4% of all cases. Crude 30-day operative mortality was 3.6% for all procedures; 2.1% for isolated CABG, 3.6% for valve procedures, 5.2% for valve and CABG and 11.4% for other cardiac surgical procedures. Mortality rates increased from 1.8% for elective procedures to 4.1% for urgent and 24.6% for emergency or salvage operations. In comparison to international figures from the USA and UK, mortality rates following isolated CABG were lower whilst average length of hospital stay post-procedure was higher.
The ASCTS database project is now well established and the electronic database and reporting module is in operation in all participating sites. The risk-adjusted isolated operative mortality suggests cardiac surgical performance in Victoria compares well with international standards. As the database develops, local risk-adjustment models for mortality and morbidity for each procedure will be developed to enable appropriate between hospital comparisons.
[Show abstract][Hide abstract] ABSTRACT: Acute dissection of the ascending aorta is a life-threatening condition that requires timely recognition and management. Here we describe an unusual variant of acute dissection involving a localized tear in the proximal ascending aorta through the commissure of the left and noncoronary cusps of the aortic valve causing aortic regurgitation.
The Annals of thoracic surgery 08/2004; 78(1):321-3. · 3.45 Impact Factor