The heart surgery forum
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The heart surgery forum · Jan 2002
ReviewUsing the STS and multinational cardiac surgical databases to establish risk-adjusted benchmarks for clinical outcomes.
One of the purposes of collecting data on cardiac surgical procedures, at a national level is to enable individual surgeons to improve quality and benchmark their own practice by making more accurate prospective prediction of outcome of each individual patient by using risk stratification based on previous local and national experiences. The past decade has seen a dramatic increase in the development of national cardiac surgical initiatives in many countries around the world. The size and extent of these databases has successfully allowed their use for patient risk stratification and preoperative risk modeling in four main aspects: patient selection and informed consent, coherent analysis of the determinants of patient outcomes, rationalizing unit management, and negotiations with external agencies. ⋯ Unlike the STS dataset, the International Dataset incorporates EuroSCORE, a simple-to-use, validated patient risk stratification system, which has been rapidly adopted by large numbers of centers around the world for patient risk stratification, outcomes assessment, and improving patient informed consent. There are several benefits to collecting and centralizing national and international data: (1) understanding and defining basic demographics of patients undergoing cardiac surgery; (2) patient risk stratification and risk prediction at both a national and center-by-center level; (3) unit benchmarking, and development of effective nationally oriented and center-oriented quality improvement programs; (4) understanding and rationalizing resource utilization; and (5) use of data to leverage governments and other healthcare providers to affect policy. Cardiac surgical registries will soon attempt to track patients for longer follow-up periods after discharge in order to identify surgery-related deaths for more extended periods of time following surgery, thereby improving the monitoring and prediction of patient outcomes.
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The heart surgery forum · Jan 2002
Thoracic epidural anesthesia for cardiac surgery via left anterior thoracotomy in the conscious patient.
Cardiac surgery is perceived to be maximally invasive and fraught with complications. In response to this perception, cardiothoracic surgeons have been refining traditional techniques to minimize their invasive nature. Epidural anesthesia has been used safely and effectively for numerous surgical procedures to reduce morbidity associated with general anesthesia. In hopes of achieving a similar result, we set out to determine the feasibility of using thoracic epidural anesthesia for limited cardiac surgery through a left anterior thoracotomy for patients who were awake and spontaneously breathing. ⋯ Thoracic epidural anesthesia for limited cardiac surgical procedures by means of a left anterior thoracotomy is feasible, even in patients with diminished pulmonary function. Furthermore, this method offered no significant technical hurdles. Nevertheless, the applicability of this technique to other procedures remains unclear. We believe that these results warrant controlled comparison of regional versus general anesthesia for limited cardiac surgery.
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The heart surgery forum · Jan 2002
Case ReportsRepair of acute ascending aorta-arch dissection with continuous body perfusion: a case report.
An approach for the replacement of the distal ascending aorta-proximal arch and acute dissection is described. During the operation, the patient's entire body was continuously perfused, the aortic arch was excluded from the arterial circulation, and the aorta was not clamped at any time. To achieve continuous body perfusion, we independently cannulated the right axillary and the left femoral arteries. ⋯ Aggressive medical management resulted in complete patient recovery. No neurologic deficits were observed, and the patient regained full cognitive function. This report describes a simple approach to facilitate repair of the aortic arch and minimize postoperative organ failure.
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The heart surgery forum · Jan 2002
Total arterial off-pump coronary revascularization with only internal thoracic artery and composite radial artery grafts.
Total arterial off-pump coronary artery bypass (OPCAB) grafting with only internal thoracic artery (ITA) and composite radial artery (RA) grafts has been applied extensively to avoid cerebral complications and late vein graft failure. We evaluated the initial experience with this method by clinical and angiographic study. ⋯ OPCAB grafting with ITAs and composite RAs provides excellent early and intermediate clinical results and graft patency.
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The heart surgery forum · Jan 2002
Aortic and mitral valve surgery on the beating heart is lowering cardiopulmonary bypass and aortic cross clamp time.
The concept of cardiac surgery on the beating heart is acceptable rationale for the cardiac surgery in the next millenium. Beating heart (off-pump) coronary artery bypass grafting (CABG) techniques have led us to consider the possibility for performing the aortic and mitral valve surgery (mitral valve repairs and replacements - with or without CABG) on the beating heart with the technique of retrograde oxygenated coronary sinus perfusion. ⋯ We conclude that beating heart valve surgery (any combination) with or without CABG significantly lower the cardiopulmonary bypass and aortic cross clamp time. In addition, the advantages of beating-heart surgery are 1) the perfused myocardial muscle, 2) the heart is not doing any work, 3) no reperfusion injury, 4) the possibility for ablation of atrial fibrillation on the beating heart, and 5) testing of the mitral valve repair is done in real physiologic conditions in the state of left ventricle beating tonus. The procedure could be the procedure of choice for the valve operation or combined operations (valve operation and CABG) in high-risk patients with low ejection fractions. There is no doubt that at present day in cardiac surgery exist at least two major factors for mortality and morbidity after cardiac surgery, which are operation - related, namely cardiopulmonary bypass time and its duration and aortic cross clamp time (ischemic time of myocardium). In the last few years a number of different techniques emerged in the field of cardiac surgery, which were directed toward better results in the selected high risk patients or to minimize the deleterious effects of cardiopulmonary bypass (CPB) on the overall postoperative performance [Calafiore 1996, Tasdemir 1998]. Due to the fact, that the cardiac muscle should be protected at most during the cardiac arrest, retrograde blood cardioplegia was successfully introduced [Buckberg 1990], and more - the warm cardioplegia is being used recently [Kawasuji 1997]. The natural status of the human heart is the beating status, so it is reasonable to try to perform the operations on the beating heart. This has been done recently with the MID - CAB and OP - CAB (off-pump CABG) operations [Tasdemir 1998]. The retrograde warm blood cardioplegia has therefore led us to the premise, that with retrograde oxygenated blood perfusion it would be possible to achieve the operations on the beating heart even in the open heart surgery, such as aortic and/or mitral valve surgery. All will agree that the most damaging effect of the cardioplegia is the reperfusion injury [Allen 1997], and it is obvious that with the technique of retrograde continuous oxygenated blood perfusion this effect will be canceled. In this article, we would like to show the how-to technique for the operations on the beating heart in the case of operations on the aortic valve replacement (AVR) with mitral valve repair (MVR) or replacement MVR and with/without concomitant coronary artery bypass (CABG) surgery. The tricuspid valve repair (PTV) is normally done on the beating heart and there it is realized what problems or technical difficulties may arise during procedures on the mitral valve: the walls of the ventricles are not flattened and the exposure of the mitral valve is challenging task. Furthermore, the free walls of the ventricles with interventricular septum are in the state of the tonus, so every force applied to better expose the aortic or mitral valve is not acceptable