The importance of a coronary artery, based on the myocardial mass it perfuses, is well documented, but little is known about the importance of a vessel that has been bypassed and its effect on ...survival in the context of bilateral internal thoracic artery (BITA) grafting.
This study determined the effect of a dominant left anterior descending (LAD) artery and important non-LAD targets on outcomes after BITA grafting.
From January 1972 to January 2011, of 6,127 patients who underwent BITA grafting, 2,551 received 1 ITA grafted to the LAD and had an evaluable coronary angiogram. A dominant LAD was defined as one that was wrapped around the left ventricular apex. Non-LAD targets were graded based on their terminal reach toward the apex: important: >75% (n = 1,698); and less important: ≤75% (n = 853). Mean follow-up was 14 ± 8.7 years. Multivariable analysis was performed to identify risk factors for time-related mortality.
A dominant LAD was present more frequently in patients with less important additional targets (51% vs. 35%; p < 0.0001). A total of 179 patients (7.0%) received a second ITA to multiple targets, 77 (43%) of which were to multiple important target vessels. Unadjusted late survival was similar regardless of degree of importance of the second ITA target—77% at 15 years (p = 0.70) for the important and less important targets, respectively. In the multivariable model, grafting the second ITA to multiple important targets was associated with better long-term survival (p = 0.005). In patients with a nondominant LAD, a second ITA grafted to a less important artery was associated with higher risk of operative mortality (2.4% vs. 0.51%; p = 0.007). A saphenous vein graft to an important or less important target did not influence long-term survival.
In BITA grafting, bypassing multiple important targets to maximize myocardium supplied by ITAs improved long-term survival. In patients with a nondominant LAD, selecting an important target for the second ITA lowered operative mortality.
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Background
Emergency surgery, blood transfusion, and reoperation for bleeding have been associated with increased operative morbidity and mortality. The recent increased use of direct oral ...anticoagulants and antiplatelet medications has made the above more challenging. In addition, cardiopulmonary bypass (CPB), with its associated hemodilution, fibrinolysis, and platelet consumption, may exacerbate the pre‐existing coagulopathy and increase the risk of bleeding.
Aim
The aim of this study was to examine available literature with regard to treating patients who are on the above medications and require emergency cardiac surgery.
Results
Management decisions are typically made on a case‐by‐case basis. Surgery is delayed when possible, and less invasive percutaneous options should be considered if feasible. Attention is paid to exercising meticulous techniques, avoiding excessive hypothermia, and treating coexisting issues such as sepsis. Ensuring a dry operative field upon entry by correcting the coagulopathy with reversal agents is offset by the concern of potentially hindering efforts to anticoagulate the patient (heparin resistance) in preparation for CPB, in addition to possibly increasing the risk of thromboembolism.
Conclusion
Proper knowledge of anticoagulants, their reversal agents, and the usefulness of laboratory testing are all essential. Platelet transfusion remains the mainstay for antiplatelet medications. Four‐factor prothrombin complex concentrate is considered in patients on oral anticoagulants if CPB needs to be instituted quickly. Specific reversal agents such as idarucizumab and andexanet alfa can be considered if significant tissue dissection is anticipated, such as redo sternotomy, but are costly and may lead to heparin resistance and anticoagulant rebound.
Oral anticoagulants and antiplatelet medications with their reversal agents
Background
Cardiac surgery accounts for 10–15% of blood transfusions in the US, despite benefits and calls of limiting its use. We sought to evaluate the impact of a restrictive transfusion protocol ...on blood use and clinical outcomes in patients undergoing isolated primary coronary artery bypass grafting (CABG).
Methods
Blood conservation measures, instituted in 2012, include preoperative optimization, intraoperative anesthesia, and pump fluid restriction with retrograde autologous priming and vacuum‐assisted drainage, use of aminocaproic acid and cell saver, intra‐ and postoperative permissive anemia, and administration of iron and low‐dose vasopressors if needed. Medical records of patients who underwent isolated primary CABG from 2009 to 2012 (group A; n = 375) and 2013 to 2016 (group B; n = 322) were compared.
Results
CABG with grafting to three or four coronary arteries was performed in 262 (70%) and 222 (69%) patients and bilateral internal thoracic artery grafting in 202 (54%) and 196 (61%) patients in groups A and B, respectively. Mean preoperative and intraoperative hematocrit was 40.3% and 40.7%, 28.9% and 29.4% in groups A and B, respectively. Total blood transfusion was 24% and 6.5%, intraoperative transfusion 11% and 1.2%, and postoperative transfusion 20% and 5.6% (P < .0001 for all) in groups A and B, respectively. Median postoperative length of stay was 5.0 days in group A and 4.5 days in group B (P = .02), with no significant differences in mortality or morbidity.
Conclusions
A restrictive transfusion protocol reduced blood transfusions and postoperative length of stay without adversely affecting outcomes following isolated primary CABG.
Objective: To determine the durability of repair of a bicuspid aortic valve with leaflet prolapse, and to identify factors associated with repair failure. Methods: From November 1988 to January 1997, ...94 patients with a bicuspid aortic valve and regurgitation from leaflet prolapse had aortic valve repair. In 66 patients, the repair employed triangular resection of the prolapsing leaflet. The remainder underwent mid-leaflet plication of the prolapsing leaflet. Mean age was 38±10 years and 93% were male. Median follow-up was 5.5 years (range 0.2–9 years). Factors associated with aortic valve competence and durability were identified by multivariable logistic and hazard function analyses. Results: Early valve competence was more difficult to achieve in patients with large, poor functioning ventricles (P=0.02). Aortic valve reoperation was necessary in 12 patients that included three re-repairs and nine aortic valve replacements. Freedom from reoperation was 95, 87 and 84% at 1, 5 and 7 years, respectively. The instantaneous risk of reoperation was highest immediately after operation, and fell rapidly to approximately 2% per year and less after 2 years. The only risk factor identified was the presence of residual aortic regurgitation (trace to mild in 35 cases) on immediate intraoperative post-repair transesophageal echocardiography. Late aortic regurgitation did not progress detectably across time (P=0.3). There were no deaths, early or late. Conclusion: Bicuspid aortic valve repair for prolapsing leaflet is a safe procedure with good intermediate-term outcome. However, any residual aortic regurgitation jeopardizes repair durability and initial repair achievement is more difficult in patients with dilated, poor functioning ventricles.
Objective: To determine the durability of repair of a bicuspid aortic valve with leaflet prolapse, and to identify factors associated with repair failure. Methods: From November 1988 to January 1997, ...94 patients with a bicuspid aortic valve and regurgitation from leaflet prolapse had aortic valve repair. In 66 patients, the repair employed triangular resection of the prolapsing leaflet. The remainder underwent mid-leaflet plication of the prolapsing leaflet. Mean age was 38±10 years and 93% were male. Median follow-up was 5.5 years (range 0.2-9 years). Factors associated with aortic valve competence and durability were identified by multivariable logistic and hazard function analyses. Results: Early valve competence was more difficult to achieve in patients with large, poor functioning ventricles (P=0.02). Aortic valve reoperation was necessary in 12 patients that included three re-repairs and nine aortic valve replacements. Freedom from reoperation was 95, 87 and 84% at 1, 5 and 7 years, respectively. The instantaneous risk of reoperation was highest immediately after operation, and fell rapidly to approximately 2% per year and less after 2 years. The only risk factor identified was the presence of residual aortic regurgitation (trace to mild in 35 cases) on immediate intraoperative post-repair transesophageal echocardiography. Late aortic regurgitation did not progress detectably across time (P=0.3). There were no deaths, early or late. Conclusion: Bicuspid aortic valve repair for prolapsing leaflet is a safe procedure with good intermediate-term outcome. However, any residual aortic regurgitation jeopardizes repair durability and initial repair achievement is more difficult in patients with dilated, poor functioning ventricles.
Small-bowel diverticulosis is a rare entity that can be discovered incidentally during celiotomy, endoscopy, or radiographic imaging studies. The reported complication rate is low, giving rise to the ...current recommendation not to treat uncomplicated small-bowel diverticula.
A retrospective review was performed of patients with small-bowel diverticulosis seen during 23 years at three major institutions.
Two hundred eight patients were identified. Diverticula were located in the duodenum in 79 percent; in the jejunum or ileum in 18 percent; and in duodenum, jejunum, and ileum in 3 percent. Complications developed in 42 of the 208 patients (20 percent) including bleeding in 14, diverticulitis with perforation and abscess formation in 12, and malabsorption in 8. When assessed by location, jejunoileal diverticula were more likely to have complications than duodenal diverticula: 46 percent compared to 13 percent (p < .01). Bleeding accounted for 52 percent of the duodenal complications compared to 12 percent of the jejunoileal complications (p < 05). Jejunoileal diverticula were more likely to perforate and develop abscesses (21 percent compared to 1.2 percent; p < .001).
The low incidence of complications associated with duodenal diverticula justifies a nonoperative approach. The higher complication rate associated with jejunoileal diverticula will be necessary to define that approach more exactly.
Outcomes may be improved by purposefully delaying surgical intervention of the traumatically ruptured descending thoracic aorta.
Fifty-seven patient records identified through the Trauma Registry of ...a level 1 trauma center between January 1993 and April 2002 were retrospectively analyzed between groups who underwent “clamp-and-sew” versus partial left heart bypass repair techniques and between emergent versus delayed repair.
Thirty-two (56%) of 57 patients were male. The mean age among survivors and nonsurvivors was 41 ± 18 (range 13 to 70) and 52 ± 23 (range 18 to 92;
p = 0.04) years, and Injury Severity Score was 31 ± 13 (range 17 to 75) and 40 ± 16 (range 16 to 75;
p = 0.04) points, respectively. Thirty-one (54%) underwent surgical intervention, 20 (35%) died during their initial resuscitation, and 6 (11%) were managed nonoperatively. Seventeen (55%) were repaired using partial left heart bypass and 14 (45%) using the clamp technique. Twenty-one (68%) had emergent repair and 10 (32%) had delayed repair. The rates of paraplegia, renal failure, and mortality were 12% (2 of 17), 0%, and 24% (4 of 17) in the bypass group, 0% (
p = 0.29), 0%, and 36% (5 of 14,
p = 0.36) in the clamp group, 9.5% (2 of 21), 0%, and 38% (8 of 21) in the emergent group (<24 hours after admission), and 0% (
p = 0.45), 0%, and 10% (1 of 10,
p = 0.12) in the delayed group (>24 hours after admission), respectively. Mean clamp times for the bypass and clamp groups were 44 ± 18 (21 to 90) and 30 ± 10 (14 to 52) minutes, respectively (
p = 0.02). Overall operative mortality was 29% (9 of 31).
Purposefully delaying surgical intervention in selected cases of descending thoracic aortic rupture and using the clamp technique does not increase mortality or morbidity over immediate operation and use of partial left hear bypass.
Our objective was to determine the incidence, management, and outcome of traumatic pancreatic injury. A retrospective review was performed of all patients with pancreatic injury admitted to two Level ...I trauma hospitals over a 10-year period. Comparisons were made with Chi square or Fisher's exact tests. Of 16,188 trauma admissions, 72 patients (0.4%) had pancreatic injury. The mean age was 30 years, and 30 patients (69%) were male. Mechanism of injury was gunshot in 32 (45%), blunt in 27 (37%), and stab wound in 13 (18%). The pancreas was involved in 1.1 per cent of patients with penetrating injuries compared to 0.2 per cent with blunt injuries (P < 0.01). There were 18 grade I (25%), 32 grade II (45%), 16 grade III (22%), and 5 grade IV (7%) injuries. Initial diagnosis was made intraoperatively in 63 patients and by computed tomography in 8. The mean injury grade was significantly lower on computed tomography compared to surgical exploration (0.4 vs 2.0; P < 0.05). Operative procedures included distal pancreatectomy in 23 (32%), exploration only in 22 (31%), external drainage in 13 (18%), pancreatorrhaphy in 4, internal drainage in 2, and proximal resection in 2. Mortality was 16.6 per cent and was not related to the mechanism or grade of injury. Mean Injury Severity Score and transfusion requirements were significantly greater in patients who died (P < 0.05). Morbidity occurred in 30 patients (42%), including pancreatic fistula (11%), pancreatitis (7%), and pancreatic pseudocyst (3%). Six patients (8%) developed intra-abdominal abscesses, and all had associated liver or intestinal injuries. In patients with grade I and II injuries, morbidity was higher with external drainage compared to exploration without drainage. Pancreatic injury is infrequent and is more often associated with penetrating trauma. Diagnosis is most commonly made by exploration and cannot be excluded by computed tomography. Drainage of low-grade injuries may not be necessary. Morbidity and mortality in patients with pancreatic trauma is significant and is primarily due to associated injuries.
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