Interactive cardiovascular and thoracic surgery
-
Interact Cardiovasc Thorac Surg · Sep 2013
Pre-existing endothelial cell activation predicts vasoplegia after mitral valve surgery.
Post-cardiac surgery vasoplegia is a common complication of cardiac surgery, characterized by profound loss of systemic vascular resistance. This results in severe hypotension, high cardiac output and metabolic acidosis reflecting inadequate tissue perfusion. The pathophysiological mechanisms underlying this syndrome remain unknown. We hypothesized that this vasoplegia reflects endothelial dysfunction, either as pre-existing condition or as a consequence of the surgical procedure. ⋯ Pre-existing endothelial cell activation, reflected by higher baseline von Willebrand Factor propeptide and sP-selectin levels, is a predisposing factor for post-cardiac surgery vasoplegia. The pre-existing endothelial cell activation may have resulted in desensibilization of endothelium in patients who develop vasoplegic syndrome, resulting in no myocardial release of endothelial cell activation markers upon reperfusion.
-
Interact Cardiovasc Thorac Surg · Sep 2013
External validity of the Society of Thoracic Surgeons risk stratification tool for deep sternal wound infection after cardiac surgery in a UK population.
Deep sternal wound infection (DSWI) is a devastating complication of cardiac surgery, with a historical incidence of 0.4-5%. Predicting which patients are at higher risk of infection may help instituting various preventive measures. Risk calculations for mortality have been used as surrogates to estimate the risk of deep sternal wound infection, with limited success. The Society of Thoracic Surgeons (STS) 2008 Risk Calculator modelled the risk of DSWI for cardiac surgical patients, but it has not been validated since its publication. We sought to assess the external validity of the STS-estimated risk of DSWI in a United Kingdom (UK) population. ⋯ The STS risk calculator lacks adequate discriminatory power for estimating the isolated risk of developing deep sternal wound infection in a UK population. The discrimination is similar to the tool's validation c-statistic and may have a place in an integrated calculator.
-
Interact Cardiovasc Thorac Surg · Sep 2013
ReviewHEARTSTRING enabled no-touch proximal anastomosis for off-pump coronary artery bypass grafting: current evidence and technique.
Surgical revascularization remains the standard of care for many patients. Off-pump coronary artery bypass grafting (OPCAB) without cardiopulmonary bypass (CPB) has evolved during the past 20 years, and as such can significantly reduce the occurrence of neurological complications. While avoiding the aortic cross-clamping required in conventional on-pump techniques, OPCAB results in a lower incidence of stroke. ⋯ However, this technique may not be applicable to for every patient as the use of free grafts (arterial or venous) requiring proximal anastomosis is often still necessary to achieve complete revascularization. In these situations, proximal anastomosis can be performed without a partial clamp by using the HEARTSTRING device, and over the last few years, considerable evidence has arisen supporting the impact of HEARTSTRING-enabled anastomosis to significantly minimize atheroembolism and neurological complications when compared with partial- or side-bite clamping. This paper provides a systematic overview and technical information about the combination of OPCAB and clampless strategies using the HEARTSTRING for proximal anastomosis to reduce stroke to levels reported for percutaneous coronary intervention.
-
Interact Cardiovasc Thorac Surg · Sep 2013
ReviewWhen should cardiopulmonary bypass be used in the setting of severe hypothermic cardiac arrest?
A best evidence topic was written according to a structured protocol. The question addressed was regarding the indication and timing of the use of cardiopulmonary bypass (CPB), following severe hypothermic cardiac arrest. A total of 284 papers were found using the reported searches, of which nine represented the best evidence to answer the clinical question. ⋯ A retrospective study analysing long-term neurological outcomes of survivors reported normal history and physical examination in 93.3%, normal neurovascular ultrasound in 100%, normal neuropsychological findings in 93.3% and normal brain magnetic resonance imaging in 86.7%. A small comparative study demonstrated a significant survival benefit when CPB was preceded with emergency thoracotomy, internal cardiac massage and warm mediastinal irrigation compared with CPB alone. We conclude that, following deep hypothermic circulatory arrest, the urgent use of cardiopulmonary bypass is widely indicated for rewarming where it has been shown to provide good survival and neurological outcomes far superior in comparison with conventional methods of rewarming.
-
Interact Cardiovasc Thorac Surg · Sep 2013
ReviewBicuspid aortic valve aortopathy: genetics, pathophysiology and medical therapy.
The association between ascending aortic aneurysm (AA) and bicuspid aortic valve (BAV) has been well established. Different genetic, haemodynamic and cardiovascular risk factors have been implicated in the development and progression of AA. ⋯ MeSH terms included: 'bicuspid aortic valve and ascending aorta', 'bicommissural aortic valve and aneurysm', 'bicuspid aortopathy', 'bicuspid aortic valve pathophysiology', 'bicuspid aortic valve and genetics' and 'bicuspid aortic valve and treatment'. We aim in this review to discuss the mechanisms, pathophysiology, genetics and modern drug therapy in the context of BAV-associated aortopathy.