[show abstract][hide abstract] ABSTRACT: We conducted a study to assess pharmacokinetics of high-dose tranexamic acid for 24 h after administration of the drug in patients undergoing cardiac surgery with cardiopulmonary bypass. High-dose tranexamic acid involved a bolus of 30 mg.kg(-1) infused over 15 min followed by a 16 mg.kg(-1) .h(-1) infusion until chest closure with a 2 mg.kg(-1) load within the pump prime. Tranexamic acid followed first-order kinetics best described using a two-compartment model, with a total body clearance that approximated the glomerular filtration rate. Mean plasma tranexamic acid concentrations during the intra-operative period and in the first 6 postoperative hours were consistently higher than the suggested threshold to achieve 100% inhibition and 80% inhibition of tissue plasminogen activator. With recent studies implicating high-dose tranexamic acid as a possible aetiology of postoperative seizures following cardiac surgery, the minimum effective yet safe dose of tranexamic acid in high-risk cardiac surgery needs to be refined.
[show abstract][hide abstract] ABSTRACT: Three-dimensional (3D) transesophageal echocardiography (TEE) is more accurate than two-dimensional (2D) TEE in the qualitative assessment of mitral valve (MV) prolapse (MVP). However, the accuracy of 3D TEE in quantifying MV anatomy is less well studied, and its clinical relevance for MV repair is unknown.
The number of prolapsed segments, leaflet heights, and annular dimensions were assessed using 2D and 3D TEE and compared with surgical measurements in 50 patients (mean age, 61 ± 11 years) who underwent MV repair for mainly advanced MVP.
Three-dimensional TEE was more accurate (92%-100%) than 2D TEE (80%-96%) in identifying prolapsed segments. Three-dimensional TEE and intraoperative measurements of leaflet height did not differ significantly, while 2D TEE significantly overestimated the height of the posterior segment P1 and the anterior segment A2. Three-dimensional TEE quantitative MV measurements were related to surgical technique: patients with more complex MVP (one vs two to four vs five or more prolapsed segments) showed progressive enlargement of annular anteroposterior (31 ± 5 vs 34 ± 4 vs 37 ± 6 mm, respectively, P = .02) and commissural diameters (40 ± 6 vs 44 ± 5 vs 50 ± 10 mm, respectively, P = .04) and needed increasingly complex MV repair with larger annuloplasty bands (60 ± 13 vs 67 ± 9 vs 72 ± 10 mm, P = .02) and more neochordae (7 ± 3 vs 12 ± 5 vs 26 ± 6, P < .01).
Measurements of MV anatomy on 3D TEE are accurate compared with surgical measurements. Quantitative MV characteristics, as assessed by 3D TEE, determined the complexity of MV repair.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 04/2012; 25(7):758-65. · 2.98 Impact Factor
[show abstract][hide abstract] ABSTRACT: Purpose: Non-steroidal anti-inflammatory drugs (NSAIDs) are used as analgesic in postoperative pain to reduce opioid side effects,
such as drowsiness and nausea. However, NSAIDs have not been used extensively in cardiac surgical patients due to the fear
of untoward effects on gastric, renal, and coagulation parameters. This study will evaluate the efficacy and safety of three
NSAIDs for pain control in CABG patients.
Methods: One hundred and twenty patients scheduled for elective CABG surgery were enrolled in randomized, double blind, controlled
study. Standardized fast track cardiac anesthesia was used. One dose of drug (75 mg diclofenac, 100 mg ketoprofen, 100 mg
indomethacin, or placebo) was givenpr one hour before tracheal extubation and a second dose 12 hr later. Pain was treated with morphineiv and acetaminophenpo. Visual analogue pain scores were recorded at baseline, 3, 6, 12 and 24 hr after the first dose of drug.
Results: There were no differences among the groups in pain scores. Only patients who received diclofenac required less morphine
than patients in the control group (P<0.05). When the total amounts of pain medications were computed to morphine equivalents, only patients in the diclofenac
group received less pain medications than the placebo group (P<0.05). Proportion of patients with postoperative increase of creatinine level (20% and over) did not differ between placebo
and drug groups.
Conclusion: Non-steroidal anti-inflammatory drugs may be used for anaalgesia management post CABG surgery in selected patients. Diclofenac
appears to have the best analgesic effects by reducing the morphine and other analgesic requirement postoperatively.
Objectif: Les anti-inflammatoires non stéroïdiens (AINS) servent d’analgésique postopératoire et réduisent les effets secondaires
des opioïdes, comme la somnolence et les nausées. Leur emploi en cardiochirurgie est plutôt restreint où on craint des effets
gastriques et rénaux indésirables et des modifications de la coagulation. On a voulu évaluer l’efficacité et la sécurité d’emploi
analgésique de trois AINS chez des patients qui subissent un pontage aortocoronarien.
Méthode: L’étude randomisée, contrôlée et à double insu a porté sur 120 patients qui devaient subir un pontage aortocoronarien. Une
anesthésie cardiaque normalisée pour un séjour hospitalier écourté a été utilisée. Une dose de médicament (75 mg de diclofénac,
100 mg de kétoprofène, 100 mg d’indométhacine, ou un placebo) a été administréepr une heure avant l’extubation endotrachéale et une seconde dose 12 h plus tard. La douleur a été traitée avec de la morphineiv et de l’acétaminophènepo. Les scores de douleur ont été enregistrés à l’échelle visuelle analogique au début, puis 3, 6, 12 et 24 h après la première
dose de médicament.
Résultats: Les scores de douleur n’ont pas présenté de différence intergroupe. Seuls les patients du groupe diclofénac ont demandé
moins de morphine que ceux du groupe témoin (P<0,05). Lorsque les quantités totales d’analgésiques ont été calculées en équivalents de morphine, seuls les patients du groupe
diclofénac avaient reçu moins d’analgésique que les témoins (P<0,05). La proportion de patients qui présentaient une augmentation postopératoire du niveau de créatinine (20 % et plus)
ne différait pas du groupe placebo aux autres groupes.
Conclusion: Les anti-inflammatoires non stéroïdiens sont utiles en analgésique postopératoire chez des patients qui subissent un pontage
aortocoronarien planifié. Le diclofénac semble offrir la meilleure analgésie en réduisant les besoins de morphine et d’autres
Canadian Journal of Anaesthesia 04/2012; 47(12):1182-1187. · 2.13 Impact Factor
[show abstract][hide abstract] ABSTRACT: To evaluate the incidence of perivalvular leaks (PVLs) after valve replacement and assess its impact on immediate postoperative outcomes.
A retrospective review.
A tertiary care university hospital.
Four hundred forty-two consecutive patients undergoing aortic (AVR) and/or mitral (MVR) valve replacement.
All patients had comprehensive intraoperative transesophageal echocardiography. Follow-up transthoracic echocardiography was performed at 5 to 7 days and 1 year after surgery. PVLs were classified as trace, mild, moderate, and severe. Perioperative variables including demographic data, surgical characteristics including the degree of valve calcification, and postoperative outcomes were compared between patients with and without PVLs. Multivariate logistic regression analysis was used to identify the variables predictive of PVLs. PVLs were identified in a total of 53 (12%) patients, 29 (13%) after MVR and 24 (11%) after AVR. At the 1-year transthoracic echocardiographic follow-up, 2 (7%) of 27 patients had residual PVLs after MVR and none after AVR. The duration of cardiopulmonary bypass (CPB) was predictive of PVLs. The presence of PVLs was associated with postoperative sepsis.
The incidence of PVLs was similar after MVR and AVR. Bioprosthetic MVR and mechanical AVR were associated with higher-incidence PVLs when compared with controls. Mitral annular calcification was a potential risk factor for PVLs with bioprosthetic valves. The prolonged CPB time was predictive of PVLs. After adjusting for covariates, the overall presence of PVLs was associated with an increased risk of sepsis after surgery.
Journal of cardiothoracic and vascular anesthesia 03/2011; 25(4):610-4. · 1.06 Impact Factor
[show abstract][hide abstract] ABSTRACT: Postoperative nausea and vomiting (PONV) are significant morbidities following cardiac surgery. The purpose of this study was to determine if application of a nasogastric (NG) tube during cardiac surgery can reduce the prevalence of postoperative PONV.
This study was a prospective randomized controlled trial.
University tertiary referral center.
Two hundred two patients undergoing elective cardiac procedures.
Patients were prospectively enrolled and randomized to either receive or not receive an NG tube after induction of anesthesia. Standard anesthetic technique and postoperative care were employed in all patients. Preoperative demographic data, pain score, nausea score and incidence of vomiting were recorded early (0-8 hours) and late (8-16 hours) following extubation. Antiemetic and analgesic medications were compared between the 2 groups.
One hundred three patients were randomized to no an NG tube (controls) and 99 received an NG tube as part of their perioperative management. Demographic data and surgical characteristics were similar between the 2 groups. However, the control group had more smokers. Incidence and severity of nausea, pain scores, and analgesic requirements were similar between the 2 groups. Prevalence of vomiting was more frequent in the control group (24%) than in the NG tube group (10%, p = 0.007), and was more frequent in patients who underwent valve and redo procedures.
Use of an NG tube during cardiac surgery may reduce the incidence of postoperative vomiting.
Journal of cardiothoracic and vascular anesthesia 02/2011; 25(1):105-9. · 1.06 Impact Factor
[show abstract][hide abstract] ABSTRACT: We report the case of a left-sided migrated 'Sideris button' atrial septal defect occlusion device 6 years post-implantation with a residual secundum atrial septal defect and left atrial mass. The aims of this case report are to highlight an uncommonly seen atrial septal occlusion device, the importance of a complete echocardiographic examination of the path traversed by the device to assess for local trauma to structures, and the additional anatomical information gained and diagnostic use of intraoperative 3D transoesophageal echocardiography.
[show abstract][hide abstract] ABSTRACT: Delirium is an acute deterioration of brain function characterized by fluctuating consciousness and an inability to maintain attention. Use of statins has been shown to decrease morbidity and mortality after major surgical procedures. The objective of this study was to determine an association between preoperative administration of statins and postoperative delirium in a large prospective cohort of patients undergoing cardiac surgery with cardiopulmonary bypass.
After Institutional Review Board approval, data were prospectively collected on consecutive patients undergoing cardiac surgery with cardiopulmonary bypass from April 2005 to June 2006 in an academic hospital. All patients were screened for delirium during their hospitalization using the Confusion Assessment Method in the intensive care unit. Multivariable logistic regression analysis was used to identify independent perioperative predictors of delirium after cardiac surgery. Statins were tested for a potential protective effect.
Of the 1,059 patients analyzed, 122 patients (11.5%) had delirium at any time during their cardiovascular intensive care unit stay. Administration of statins had a protective effect, reducing the odds of delirium by 46%. Independent predictors of postoperative delirium included older age, preoperative depression, preoperative renal dysfunction, complex cardiac surgery, perioperative intraaortic balloon pump support, and massive blood transfusion. The model was reliable (Hosmer-Lemeshow test, P = 0.3) and discriminative (area under receiver operating characteristic curve = 0.77).
Preoperative administration of statins is associated with the reduced risk of postoperative delirium after cardiac surgery with cardiopulmonary bypass.
[show abstract][hide abstract] ABSTRACT: We present a rare complication after open-heart surgery resulting in compression of the superior vena cava (SVC) with the concurrent findings of the hypertrophic obstructive cardiomyopathy physiology. A 59-year-old woman developed a low cardiac output syndrome, persistent hypotension, and increasing filling pressures after emergency replacement of the ascending aorta and resuspension of the aortic valve due to a type A aortic dissection. Transesophageal echocardiography (TEE) evaluation revealed partial SVC obstruction, under-filled left ventricle (LV), and a persistent mitral systolic anterior motion with increasing pressure gradient in the left ventricular outflow tract (LVOT). Surgical exposure uncovered an intrapericardial thrombus around the aortic graft compressing the SVC. Removal of the thrombus resulted in immediate haemodynamic improvement and elimination of both SVC and LVOT obstructions. A comprehensive TEE exam should always be performed, and all the structures should be visualized for the proper diagnosis and management of patients after cardiac surgery.
[show abstract][hide abstract] ABSTRACT: Patients with aortic atheroma are at increased risk for neurological injury after coronary artery bypass graft (CABG) surgery. We sought to determine the role of epiaortic ultrasound scanning for reducing cerebral embolic load, and whether its use leads to changes of planned intraoperative surgical management in patients undergoing CABG surgery.
Patients >70-yr-of-age scheduled for CABG surgery were prospectively randomized to either an epiaortic scanning (EAS) group (aortic manipulation guided by epiaortic ultrasound) or a control group (manual aortic palpation without EAS). All patients received a comprehensive transesophageal echocardiographic examination. Transcranial Doppler (TCD) was used to monitor the middle cerebral arteries for emboli continuously from 2 min before aortic cannulation to 2 min after aortic decannulation. Neurological assessment was performed with the National Institute of Health stroke scale before surgery and at hospital discharge. The NEECHAM confusion scale was used for assessment and monitoring of patient global cognitive function on each day after surgery until hospital discharge.
Intraoperative surgical management was changed in 16 of 55 (29%) patients in the EAS group and in 7 of 58 (12%) patients in the control group (P = 0.025). These changes included adjustments of the ascending aorta cannulation site for cardiopulmonary bypass (CPB), the avoidance of aortic cross-clamping by using ventricular fibrillatory arrest during surgery, or by conversion to off-pump surgery. During surgery, 7 of 58 (12%) patients in the control group crossed over to the EAS group based on the results of manual aortic palpation. The median [range] TCD detected cerebral embolic count did not differ between the EAS and control groups during aortic manipulations (EAS, 11.5 [1-516] vs control, 22.0 [1-160], P = 0.91) or during CPB (EAS, 42.0 [4-516] vs control, 63.0 [5-758], P = 0.46). The NEECHAM confusion scores and National Institute of Health stroke scale scores were similar between the two groups.
These results show that the use of EAS led to modifications in intraoperative surgical management in almost one-third of patients undergoing CABG surgery. The use of EAS did not lead to a reduced number of TCD-detected cerebral emboli before or during CPB.
Anesthesia and analgesia 06/2008; 106(6):1611-8. · 3.08 Impact Factor
[show abstract][hide abstract] ABSTRACT: Antifibrinolytic agents are commonly used during cardiac surgery to minimize bleeding and to reduce exposure to blood products. We sought to determine whether aprotinin was superior to either tranexamic acid or aminocaproic acid in decreasing massive postoperative bleeding and other clinically important consequences.
In this multicenter, blinded trial, we randomly assigned 2331 high-risk cardiac surgical patients to one of three groups: 781 received aprotinin, 770 received tranexamic acid, and 780 received aminocaproic acid. The primary outcome was massive postoperative bleeding. Secondary outcomes included death from any cause at 30 days.
The trial was terminated early because of a higher rate of death in patients receiving aprotinin. A total of 74 patients (9.5%) in the aprotinin group had massive bleeding, as compared with 93 (12.1%) in the tranexamic acid group and 94 (12.1%) in the aminocaproic acid group (relative risk in the aprotinin group for both comparisons, 0.79; 95% confidence interval [CI], 0.59 to 1.05). At 30 days, the rate of death from any cause was 6.0% in the aprotinin group, as compared with 3.9% in the tranexamic acid group (relative risk, 1.55; 95% CI, 0.99 to 2.42) and 4.0% in the aminocaproic acid group (relative risk, 1.52; 95% CI, 0.98 to 2.36). The relative risk of death in the aprotinin group, as compared with that in both groups receiving lysine analogues, was 1.53 (95% CI, 1.06 to 2.22).
Despite the possibility of a modest reduction in the risk of massive bleeding, the strong and consistent negative mortality trend associated with aprotinin, as compared with the lysine analogues, precludes its use in high-risk cardiac surgery. (Current Controlled Trials number, ISRCTN15166455 [controlled-trials.com].).
New England Journal of Medicine 06/2008; 358(22):2319-31. · 51.66 Impact Factor
[show abstract][hide abstract] ABSTRACT: The purpose of this study was to determine the prevalence of claustrophobia in patients undergoing magnetic resonance imaging (MRI) after coronary artery bypass graft (CABG) surgery.
After IRB approval, we conducted a substudy of a prospective randomized controlled clinical trial of 311 patients evaluating administration of tranexamic acid and early saphenous vein graft patency with MRI after conventional CABG surgery. Chest tube drainage was measured at 6, 12, and 24 hours after surgery. The rate of transfusion and the amount of red blood cells (RBC), fresh frozen plasma (FFP), and platelets transfused were recorded.
A total of 237(76%) patients underwent MRI after surgery. 39 (14%, [95% CI, 10.2 to 18.0]) patients experienced severe anxiety caused by a fear of enclosed space in the MRI coil necessitating termination of the procedure. Patients with claustrophobia were on average 5 years younger. They were more likely to have diabetes mellitus and hypertension. Patients with claustrophobia had increased chest tube drainage during the postoperative period. The rate of blood product transfusion was similar between the two groups but patients with claustrophobia who were transfused received significantly more RBC and FFP than patients without claustrophobia.
Postoperative claustrophobia and anxiety, leading to inability to undergo MRI, may be more common than previously described.
Neuropsychiatric Disease and Treatment 05/2008; 4(2):487-93. · 2.00 Impact Factor
[show abstract][hide abstract] ABSTRACT: Cerebral microembolization during cardiopulmonary bypass may lead to cognitive decline after cardiac surgery. Transfusion of the unprocessed shed blood (major source of lipid microparticulates) into the patient during cardiopulmonary bypass is common practice to reduce blood loss and blood transfusion. Processing of shed blood with cell saver before transfusion may limit cerebral microembolization and reduce cognitive decline after surgery.
A total of 226 elderly patients were randomly allocated to either cell saver or control groups. Anesthesia and surgical management were standardized. Epiaortic scanning of the proximal thoracic aorta was performed in all patients. Transcranial Doppler was used to measure cerebral embolic rates. Standardized neuropsychological testing was conducted 1 week before and 6 weeks after surgery. The raw scores for each test were converted to Z scores, and then a combined Z score of 10 main variables was calculated for both study groups. The primary analysis was based on dichotomous composite cognitive outcome with a 1-SD rule. Cognitive dysfunction was present in 6% (95% confidence interval, 1.3% to 10.7%) of patients in the cell saver group and 15% (95% confidence interval, 8% to 22%) of patients in the control group 6 weeks after surgery (P=0.038). The severity of aortic atheroma and cerebral embolic count were similar between the 2 groups.
The present report demonstrates that processing of shed blood with cell saver results in clinically significant reduction in postoperative cognitive dysfunction after cardiac surgery. These findings emphasize the clinical importance of lipid embolization in contributing to postoperative cognitive decline in patients exposed to cardiopulmonary bypass.
[show abstract][hide abstract] ABSTRACT: Pulmonary atelectasis and hypoxemia remain considerable problems after cardiac surgery. The objective of this study was to determine the efficacy of consecutive vital capacity maneuvers (C-VCMs) to improve oxygenation in patients after cardiac surgery.
Randomized, controlled clinical trial.
Tertiary referral teaching center.
Ninety-five patients requiring elective cardiac surgery with cardiopulmonary bypass (CPB).
Patients were randomly allocated to either C-VCM or control groups. In the C-VCM group, lung inflation at pressure of 35 cmH(2)O was sustained for 15 seconds before separation from CPB and at 30 cmH(2)O for 5 seconds after admission to the intensive care unit (ICU).
The primary outcome was the ratio of arterial oxygen tension to inspired oxygen fraction measured at the following predetermined time intervals: after induction of anesthesia, 15 minutes after separation from CPB, after admission to the ICU, after 3 hours of positive-pressure ventilation, after extubation, and before ICU discharge. C-VCM resulted in better arterial oxygenation extending from the immediate postoperative period to approximately 24 hours after surgery at the time of ICU discharge. There were no significant adverse events related to C-VCM application.
C-VCM is an effective method to reduce hypoxemia associated with the formation of atelectasis after cardiac surgery with CPB.
Journal of Cardiothoracic and Vascular Anesthesia 07/2007; 21(3):375-8. · 1.45 Impact Factor