Interactive cardiovascular and thoracic surgery
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Interact Cardiovasc Thorac Surg · Apr 2010
Review Case ReportsArgatroban as a substitute of heparin during cardiopulmonary bypass: a safe alternative?
The patient with a diagnosis of heparin-induced thrombocytopenia and thrombosis who requires urgent cardiac surgery represents a formidable challenge. Among the alternatives to heparin, argatroban has gained widespread use in non-cardiac surgery patients. The object of this communication is to report our recent experience with this agent during cardiopulmonary bypass (CPB) and to review the cases previously published in order to better define indications, dosage, monitoring and limitations in cardiac surgery patients. ⋯ Because of unresolved issues like the possibility of clotting in the extracorporeal circuit and prolonged anticoagulation after discontinuing the drug, at present, the use of argatroban as a substitute of heparin during CPB should be restricted to those cases where the other thrombin inhibitors are contraindicated.
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Interact Cardiovasc Thorac Surg · Apr 2010
Randomized Controlled Trial Comparative StudyClosed cardiopulmonary bypass circuits suppress thrombin generation during coronary artery bypass grafting.
Thrombin generation is considered unavoidable during cardiac surgery using cardiopulmonary bypass (CPB). We compared the effects of open and closed circuits on coagulation and fibrinolysis under identical conditions of priming volume, heparin-coating, and anticoagulation and transfusion protocols. Thirty coronary surgery patients were randomized to surgery using open circuits with open reservoirs and cardiotomy suction (open group, n=15) or closed circuits without either (closed group, n=15). ⋯ The peak TAT value at the termination of CPB in the open group was significantly correlated with CPB time (r(2)=0.879, P=0.037) and the simultaneous peak D-dimer value (r(2)=0.640, P=0.040). In conclusion, the use of closed circuits maximally suppressed thrombin generation and coagulofibrinolytic activation during coronary artery bypass grafting. The respective contribution of open reservoirs and cardiotomy suction to the perioperative thrombin generation remains to be elucidated.
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Interact Cardiovasc Thorac Surg · Apr 2010
ReviewIn young patients with rheumatic aortic regurgitation compared to non-rheumatics is a Ross operation associated with increased incidence of autograft failure?
A best evidence topic in cardiac surgery was written, according to a structured protocol. The question addressed was: in young patients with rheumatic aortic regurgitation compared to non-rheumatics is a Ross operation associated with increased incidence of autograft failure? The pulmonary autograft with its inherent advantages of viable autologous transplant, central laminar flow, freedom from prosthetic valve complications, side effects of anticoagulation, and growth potential is considered a well-accepted option for aortic valve replacement in young patients. However, the use of a pulmonary autograft in young patients with rheumatic aortic valve disease is controversial. ⋯ All eight publications were from two institutions with one reporting outcomes for a Ross operation vs. mechanical valve implantation and two compared results of the Ross operation in rheumatic vs. non-rheumatic aortic valve disease. We conclude that the current available evidence suggests that pulmonary autograft is susceptible to rheumatic involvement. Use of pulmonary autograft in young patients (<30 years) with rheumatic aortic regurgitation and concomitant mitral regurgitation requires a cautious approach as there is an impaired autograft durability in this subgroup of patients.
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Interact Cardiovasc Thorac Surg · Apr 2010
ReviewDo bigger hospitals or busier surgeons do better adult aortic or mitral valve operations?
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether there is a relationship between hospital or surgeon volume (SV) and postoperative outcome in adult aortic or mitral valve surgery. One hundred and sixty papers were found using the specified search strategy, of which seven papers represented the best evidence to answer this question. ⋯ We conclude that regionalisation of adult aortic or mitral valve surgery based on such a limited number of modest quality studies would be an indefensible policy. The implementation of such a scheme can have many clinical, practical, economical and political consequences which have not been examined prospectively until today. Furthermore, the relationship between volume and other outcomes rather than mortality needs further assessment.
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Interact Cardiovasc Thorac Surg · Apr 2010
Randomized Controlled Trial Comparative StudyLow postoperative dose of aprotinin reduces bleeding and is safe in patients receiving clopidogrel before coronary artery bypass surgery. A prospective randomized study.
Clopidogrel (Plavix) given before the operation increases bleeding complications following coronary artery bypass grafting (CABG). High perioperative doses of aprotinin (Trasylol) are known to reduce bleeding and transfusions after cardiac surgery, but may increase the risk of thrombosis, renal impairment, and mortality. The aim of the study was to evaluate the clinical effects of aprotinin given in high doses intra- and postoperatively vs. a low postoperative dose in patients on clopidogrel. ⋯ Renal impairment and need for inotropic drugs were more frequent in the high dose group. Thirty-day mortality was similar (high dose 2%, low dose 0.5%, P=0.22). A low postoperative dose of aprotinin in patients receiving clopidogrel is safe and has comparable effects regarding postoperative bleeding complications as a high dose.