European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery
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Eur J Cardiothorac Surg · Jun 2010
Congenital heart disease: interrelation between German diagnosis-related groups system and Aristotle complexity score.
The Disease-Related Groups (DRGs) system postulates that inpatient stays with similar levels of clinical complexity are expected to consume similar amounts of resources. This, applied to surgery of congenital heart disease, suggests that the higher the complexity of procedures as estimated by the Aristotle complexity score, the higher hospital reimbursement should be. This study analyses how much case-mix index (CMI) generated by German DRG 2009 version correlates with Aristotle score. ⋯ ACC score correlates almost perfectly with corresponding cost-weights (CMI) generated by the German DRG 2009. It could therefore be used as the basis for hospital reimbursement to compensate in conformity with procedures' complexity. Extrapolated CMI in this series would be 9.264. Modulation of reimbursement according to surgical performance could be established and thus 'reward' quality in congenital heart surgery.
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Eur J Cardiothorac Surg · Jun 2010
Review Meta AnalysisLessons from aprotinin: is the routine use and inconsistent dosing of tranexamic acid prudent? Meta-analysis of randomised and large matched observational studies.
In view of the safety concerns that led to the withdrawal of aprotinin, should antifibrinolytics be used indiscriminately in cardiac surgery? This meta-analysis examines the efficacy and safety profile of tranexamic acid, and in comparison to aprotinin. We identified randomised trials and large observational studies investigating the use tranexamic acid from January 1995 to January 2009 using Pubmed/Cochrane search engine and included them in a two-tier meta-analysis. There were 25 randomised trials and four matched studies with a total of 5411 and 5977 patients, respectively, reporting tranexamic acid use in varying dosages. ⋯ Compared to aprotinin, tranexamic acid has less effective blood-conserving effect and mortality risk. Given the potential to increase neurological complications, the current trend towards indiscriminate use of tranexamic acid for all cardiac patients needs to be re-evaluated. Further studies are needed to clarify the neurological risk, appropriate indications and dosing of tranexamic acid.
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Eur J Cardiothorac Surg · Jun 2010
Comparative Study Controlled Clinical TrialUnilateral cerebral perfusion: right versus left.
Unilateral cerebral perfusion for brain protection is gaining increasing interest, although the pathways of collateral flow as well as many aspects of the surgical strategy regarding optimal perfusion pressure, flow and temperature remain unclear. This study evaluates the differences between right- and left-sided unilateral cerebral perfusion, if any, especially with regard to neurovascular monitoring findings and clinical outcome. ⋯ Unilateral cerebral perfusion under mild hypothermia is an efficient method of cerebral protection. The advantage of the right-sided perfusion in which two brain-supplying arteries are perfused could not be verified.
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Eur J Cardiothorac Surg · Jun 2010
Clinical TrialModified thromboelastography evaluation of platelet dysfunction in patients undergoing coronary artery surgery.
Anti-platelet therapy is associated with increased perioperative bleeding. Although current guidelines call for its caessation 5-10 days prior to cardiac surgery, this could constitute an increased risk of preoperative myocardial infarction. The optimal safe period from discontinuation of anti-platelet therapy to surgery is as yet unknown for the individual patient. We investigated whether preoperative thromboelastography (TEG) with platelet mapping could predict bleeding tendency in patients (on recent anti-platelet therapy) undergoing coronary artery bypass grafting (CABG). ⋯ TEG with platelet mapping is able to predict excessive postoperative blood loss among patients who underwent CABG and recent anti-platelet therapy. The prevalence of non-responsiveness to anti-platelet therapy, including clopidogrel, is higher in patients undergoing coronary artery bypass grafting than in the general population. In this study, aspirin-induced platelet dysfunction did not influence postoperative blood loss.
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Eur J Cardiothorac Surg · Jun 2010
Cerebral functions and metabolism after antegrade selective cerebral perfusion in aortic arch surgery.
Antegrade selective cerebral perfusion (ASCP) represents the best method of cerebral protection during surgery of the thoracic aorta. However, brain integrity and metabolism after antegrade cerebral perfusion have not yet been investigated. We assessed cerebral positron emission tomography (PET), diffusion-weighted imaging, proton magnetic resonance spectroscopy and cognitive functions in patients undergoing either ASCP or coronary artery bypass grafting (CABG) to elucidate whether cerebral perfusion was associated with postoperative neuronal alterations, metabolic deficit or cognitive decline. ⋯ There was no evidence of ischaemic brain injury after ASCP even if some degree of reversible brain oedema secondary to cardiopulmonary bypass (CPB) was present. The cognitive outcomes in patients undergoing ASCP were comparable to patients undergoing coronary artery bypass. The lack of left subclavian artery perfusion during cerebral perfusion leads to temporary glucose hypometabolism in the occipital lobes without neuronal injury.