Interactive cardiovascular and thoracic surgery
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Interact Cardiovasc Thorac Surg · May 2014
Review Meta AnalysisAnalgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis.
Though once considered the gold standard, epidural anaesthesia has complications that may be significant and include hypotension, urinary retention, partial or patchy block and, in rare cases, devastating neurological injuries also. Paravertebral block (PVB) is an alternative technique for unilateral surgical procedures like thoracotomy, which may offer similar analgesic effectiveness and a more favourable side-effect profile than epidural analgesia. This systematic review and meta-analysis of published randomized clinical trials aims to compare thoracic paravertebral with thoracic epidural analgesia (TEA) in thoracotomy for lung surgery. ⋯ Considering studies not included in the previous meta-analysis, a VAS score on activity at 48 h is significantly better in the PVB group (mean difference 0.40 cm; 95% confidence interval [95% CI] 0.77, 0.02; Mantel-Haenszel (M-H) fixed). Hypotension (odds ratio 0.13; 95% CI 0.06, 0.31; M-H fixed) and urinary retention are more common in the epidural analgesia group. So, we conclude that thoracic PVB may be as effective as thoracic epidural analgesia for post-thoracotomy pain relief and is also associated with fewer complications.
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Interact Cardiovasc Thorac Surg · May 2014
Optimal cut-off value for cardiac troponin I in ruling out Type 5 myocardial infarction.
The clinical classification of myocardial infarction (MI) into five types was introduced in 2007 as a component of the universal definition. A Type 5 MI was defined as a MI related to coronary artery bypass surgery. In a setting of patients undergoing elective coronary artery bypass grafting, we set out (i) to describe the pattern of multiple serial cardiac troponin I (cTnI) measurements within 72 h postoperatively and (ii) to determine the optimal cardiac troponin I cut-off value in ruling in or ruling out a Type 5 MI. ⋯ In clinically stable patients undergoing elective coronary artery bypass grafting, measurements of cTnI are useful in ruling out a Type 5 MI.
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Interact Cardiovasc Thorac Surg · May 2014
Safety considerations during transapical aortic valve implantation.
Transcatheter aortic valve implantation (TAVI) is a new method for the treatment of very high-risk patients with aortic valve stenosis. The radiation dose to which the patient and each member of the heart team are exposed during this new fluoroscopically guided intervention is unknown. ⋯ During a TA-TAVI procedure, the patients receive a higher X-ray dose than during coronary angiography with intervention. After 100 TAVI procedures, the members of the heart team sustain a comparable dose of ionizing radiation to the annual dose received by a busy interventional cardiologist. Therefore, maximal safety and optimal X-ray protection for patients and the members of the team are crucial and should be redefined.
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Interact Cardiovasc Thorac Surg · May 2014
Review Meta AnalysisAntioxidant supplementations for prevention of atrial fibrillation after cardiac surgery: an updated comprehensive systematic review and meta-analysis of 23 randomized controlled trials.
This systematic review with meta-analysis sought to determine the impact of antioxidants (N-acetylcysteine [NAC], polyunsaturated fatty acids [PUFAs] and vitamins) on incidence of postoperative atrial fibrillation (POAF) and duration of length of hospital stay. Medline, Embase, Elsevier, Sciences online database and Google Scholar literature search was made for studies in randomized controlled trials. The effect sizes measured were odds ratio (OR) for categorical variable and standard mean difference (SMD) with 95% confidence interval (CI) for calculating differences between mean values of duration of hospitalization in intervention and control groups. ⋯ Hospital length of stay was not reduced after NAC therapy (SMD: 0.082, 95% CI -0.09 to 0.25, P = 0.3), but could be decreased with PUFA (SMD: -0.185, 95% CI: -0.35 to -0.018, P = 0.03) and vitamin C (SMD: -0.325, 95% CI -0.50 to -0.14, P < 0.01). In conclusion, perioperative antioxidant supplementations with NAC, PUFA and vitamin C prevent atrial fibrillation after cardiac surgery. Moreover, PUFA and vitamin C are capable to reduce hospital stay, whereas NAC lacks this capacity.
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Interact Cardiovasc Thorac Surg · May 2014
Review Meta AnalysisA meta-analysis of adjusted risk estimates for survival from observational studies of complete versus incomplete revascularization in patients with multivessel disease undergoing coronary artery bypass grafting.
To determine whether coronary artery bypass grafting (CABG) with complete revascularization improves survival in patients with multivessel disease (MVD) over CABG with incomplete revascularization, we performed a meta-analysis of adjusted (but not unadjusted) risk estimates from observational studies. Databases including MEDLINE and EMBASE were searched through October 2013 using Web-based search engines (PubMed, OVID). Eligible studies were observational studies of complete- versus incomplete-revascularization CABG enrolling ≥ 100 patients with MVD in each treatment arm and reporting an adjusted hazard ratio for follow-up mortality. ⋯ A pooled analysis demonstrated a statistically significant 37% reduction in follow-up mortality with complete- relative to incomplete-revascularization CABG (hazard ratio, 0.63; 95% confidence interval, 0.53-0.75; P < 0.00001). Although meta-regression coefficients were not statistically significant for mean follow-up duration and age and proportion of men and patients undergoing off-pump CABG, that for proportion of patients with diabetes was significantly negative (P = 0.03), which would indicate that as patients with diabetes increase, complete-revascularization CABG is more beneficial for survival. In conclusion, complete-revascularization CABG appears to improve survival over incomplete-revascularization CABG in patients with MVD.