[Show abstract][Hide abstract] ABSTRACT: Background:
Temporary pacemaker wires are placed in the majority of patients after cardiac surgery. There is no information on mechanical factors related to wire removal.
Clinical information related to temporary wire use and removal was prospectively collected from a large cardiac surgical unit over one year. Measurements of maximal tension that nurses and doctors would apply to remove temporary wires was determined using a hand-held portable scale. In a prospective trial, patients (n = 41) had their wires extracted in series to the portable scale to determine the maximal tension required for safe removal.
Ventricular wires were placed in 86.5 % of patients during the observed year. Pacing facilitated weaning from CPB in over 15 % of patients and pacer dependence was seen in 2.1 %. No patients suffered major complications after wire removal. There was no difference in the tension that physicians or nurses would apply to comfortably extract temporary wires. In the prospective trial, there was no difference in the tension required for removal of atrial or ventricular wires (atrial 18.3 ± 17.9 oz versus 14.5 ± 14.2 oz, p = 0.430). There were no patient factors that correlated with the degree of resistance and there was no significant difference between the tension required to remove wires with (21.0 ± 22.5 oz) or without (14.1 ± 5.1 oz) an atrial button.
Temporary epicardial wire removal is innocuous and was not associated with any complications. In some patients tension required for safe removal exceeded 20 ounces. Strategies to standardize wire removal may prevent complications and may minimize unnecessary wire retention.
Preview · Article · Dec 2016 · Journal of Cardiothoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: Background:
Atelectasis is a significant complication after cardiac surgery. The current study was designed to assess the significance of atelectasis after bilateral internal thoracic artery (BITA) harvest.
The ICU admission chest x-ray of 565 patients undergoing BITA was reviewed. Linear regression modelling was used to assess the relationship between atelectasis and oxygenation as well as patient variables to length of ventilation and length of stay in the Intensive Care Unit (ICU).
Eighty-nine patients (15.8%) had Grade 2/3 atelectasis which was significantly more common on the left as compared to the right (left 0.149 95% CI [0.119-0.178], right 0.027 95% CI [0.013-0.040], p<0.001). Grade 2/3 atelectasis on the right was associated with a significant drop in the pO2 (p=0.001) and the per cent O2-fractional O2 (PF) ratio (p=0.002). Factors associated with increased ventilation time included presence of Grade 2/3 atelectasis (p=0.001) and peripheral vascular disease (PVD) (p<0.001), both of which were predictors of prolonged ICU length of stay (p=0.002 and p<0.001 respectively).
Early atelectasis is related to impaired oxygenation, prolonged ventilation and prolonged ICU stay. Future research should focus on strategies to minimise atelectasis and to determine if these changes translate into better patient outcomes.
No preview · Article · Dec 2015 · Heart, Lung and Circulation
[Show abstract][Hide abstract] ABSTRACT: Background and Aims: Skeletonization has been proposed as a technique to minimize the risk of sternal devascularization during bilateral internal thoracic artery harvest for coronary artery bypass grafting. The impact of this strategy on late radiologic pleuropulmonary changes has not been addressed.
No preview · Article · Dec 2015 · Scandinavian journal of surgery: SJS: official organ for the Finnish Surgical Society and the Scandinavian Surgical Society
[Show abstract][Hide abstract] ABSTRACT: Background:
Skeletonization is a technique of bilateral internal thoracic artery (BITA) harvest that preserves sternal blood flow. We sought to identify the relationship of skeletonization and sternal wound infection in a population undergoing BITA harvest.
Demographics and outcomes were recorded from patients undergoing coronary artery bypass graft surgery with BITA using either skeletonized (n = 531) or nonskeletonized (n = 970) techniques. The primary outcome was total infection. Propensity scores analysis as well as univariable and multivariable analysis was performed to determine the effect of skeletonization in the total cohort and in each sex.
Although patients undergoing skeletonized BITA had a lower body mass index, they were significantly older, with a higher proportion of women, diabetes mellitus, urgent or emergent surgery, renal failure, vascular and lung disease, and lower preoperative hemoglobin. There was a significant effect of skeletonization in decreasing total infection incidence (odds ratio [OR] 0.606, 95% confidence interval [CI]: 0.383 to 0.959, p = 0.032). The effect of skeletonization on total infection in men was more prominent (OR 0.466, 95% CI: 0.290 to 0.870), whereas there was no effect in women (OR 0.887, 95% CI: 0.441 to 1.786). Multivariable analysis confirmed that skeletonization was protective (OR 0.606, 95% CI: 0.383 to 0.957, p = 0.032). Other factors associated included being female (OR 3.327, 95% CI: 2.080 to 5.322, p < 0.001), insulin-dependent diabetes mellitus (OR 2.638, 95% CI: 1.506 to 4.624, p = 0.001), peripheral vascular disease (OR 2.101, 95% CI: 1.247 to 3.539, p = 0.005), increased body mass index (OR 1.100, 95% CI: 1.054 to 1.149, p < 0.001), and decreased preoperative hemoglobin (OR 0.984, 95% CI: 0.972 to 0.997, p = 0.013).
Skeletonization is associated with a significant protective effect with regard to sternal infection after coronary artery bypass graft surgery with BITA. Being female is a major risk factor for infection, and the risk is not modified significantly with a strategy of skeletonization in women.
No preview · Article · Nov 2015 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: Although one of the goals of surgical aortic valve replacement (AVR) is to alleviate congestive heart failure (CHF), the latter often occurs after AVR. Surprisingly, the incidence of CHF after AVR remains unclear, as outcomes are reported according to valve-related complications, each of which may result in CHF. The study aim was to: (i) validate a previously described model predicting persistent or recurrent CHF after AVR in a contemporary cohort; and (ii) apply the model to predict late outcomes following AVR with the Trifecta valve.
A previously described statistical model was validated in a cohort of 1,014 patients who received the St. Jude Trifecta prosthesis between 2007 and 2009. A sensitivity analysis was performed to determine the influence of risk factors associated with late CHF. Model prediction was verified with a Monte Carlo simulation employing 10,000 iterations.
The model accurately predicted late CHF events in a contemporary cohort. Sensitivity analysis identified mean transprosthesis gradient (MTG), body surface area (BSA), and preoperative NYHA class as important CHF risk factors. Based on the model, a 5 mmHg decrease in MTG was associated with 2.5% and 10.4% reductions in late CHF at five and 15 years, respectively. A 10% decrease in mean BSA and preoperative NYHA class IV symptoms were associated with a 1% decrease and a 5% increase in CHF events at 15 years after AVR.
The authors' previously described model predicting persistent or recurrent CHF after AVR was validated in a contemporary cohort. This model may be applied to predict outcomes in patients who receive modern prostheses, without long-term follow up.
No preview · Article · Nov 2014 · The Journal of heart valve disease
[Show abstract][Hide abstract] ABSTRACT: The last decade has witnessed significant developments in the use of catheter-based therapies in cardiovascular medicine. We sought to assess the educational opportunities for Cardiac Surgery trainees to determine their readiness for participation in these strategies. A web-based survey was distributed to current residents, recent graduates and Program Directors in Canadian Cardiac Surgery residency programs from 2008 to 2013. The survey was distributed to 110 residents and graduates. Forty-five percent completed the survey. Thirty-five percent expressed that they experienced resistance organizing their rotations as they had to compete with non-cardiac surgical colleagues and six were denied local cardiac catheterization rotations. By the end of the rotation 56 % were comfortable in performing a diagnostic cardiac catheterization independently. Exposure as the operator in performing diagnostic catheterization was significantly associated with the positive perception of being able to perform a diagnostic catheterization independently (OR 5.14, 95% CI[1.33-19.81], p=0.017). Eighty-eight percent of respondents expressed the need for more exposure in catheter-based rotations. Seven out of 11 Program Directors completed their survey. All of them believed such rotations should be mandatory and foresaw a bigger role for hybrid catheter-based and cardiac surgery procedures in the future. Trainees and Program Directors perceive that increased exposure to catheter-based therapies is important to career development as a cardiac surgeon. This survey will contribute to the development of cardiac surgery training curriculum as we foresee more hybrid and team procedures.
No preview · Article · Oct 2014 · The Canadian journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: This case describes a novel approach to a safe redo-sternotomy in a patient presenting with an aortocutaneous fistula from a previous infected ascending aorta graft.
[Show abstract][Hide abstract] ABSTRACT: Background: There is limited data showing long term outcomes of injection drug users (IDUs) undergoing valve replacement or repair for the treatment of infective endocarditis (IE). Although IDU may be an independent predictor of mortality, it is unclear whether this is related to immediate post operative complications or subsequent re-infection or re-admission.
Methods: Demographics and surgical data of consecutive adults who underwent valve surgery for IE were prospectively collected between January 2003 and July 2012 at our institution. Retrospective chart review was conducted, and semiparametric tests were used to determine the outcomes of all cause mortality, rate of re-infection, re-admission and re-operation.
Results: A total of 195 patients underwent valve surgery, of which 24 were identified as IDUs. IDUs had a lower mean age (39.4 vs. 59.1, p<0.0001) and body mass index (23.6 vs. 26.6, p=0.007) when compared to non-IDUs. IDUs were less likely to have hypertension (p<0.0001) and coronary artery disease (p=0.03), and more likely to have tricuspid (p=0.001) and pulmonic valve (p=0.02) involvement. No difference was observed in the initial length of hospital stay (p=0.95) or post-operative need for dialysis (p=0.40). IDU was associated with increased mortality (HR 2.79, 95% Confidence Interval [CI] 1.11 to 7.04; p=0.029), re-infection (HR 7.84, 95% CI 2.56 to 24.0; p<0.0001) and re-admission (HR 7.29, 95% CI 3.29 to 16.2; p<0.0001). Upon adjustment for co-variates, IDU was still associated with increased mortality (HR 4.38 95% CI 1.40 to 13.8, p=0.011). Although not statistically significant, there was a trend toward a higher rate of re-operation (HR 1.88 CI 0.77 to 4.58; p=0.17).
Conclusion: IDU was a predictor of mortality, re-infection and re-admission to hospital. This is despite the fact that IDUs are younger with less hypertension and coronary artery disease. In addition, there was no difference in initial post-operative complications as indicated by length of hospital stay and need for dialysis. The management of IE among IDUs is challenging and efforts to improve long term outcomes require a focus on prevention of re-infection through multi-disciplinary interventions.