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  • 1. 1. The impact of intraoperative cell autologous blood in our unit. In additionsalvage on autologous blood usage there was no major increase in the usagefollowing first time coronary artery of FFP and platelets in the cell salvagedbypass grafts (CABG) – a prospective group. survival for the same periods wereaudit 63% and 37%.Rammohan KS, Gostling J, Stevens P,Jones M, Jones C, O’Keefe PA, Dunne J › š› šDepartment of Cardiothoracic Surgery,University Hospital of Wales and College 2. Risk Factors for Requirement for Newof Medicine (UHWCM), Cardiff Haemofiltration following CardiacBackground Several studies have pointed Surgery.out the association of adverse outcomes Rammohan KS, Dunne J, Von Oppell UO.with the use of allogeneic red cells. In Department of Cardiothoracic Surgery,addition, the high cost, increased demand University Hospital of Wales & College ofand reduced supply dictates that there Medicine, Cardiff, United Kingdomshould be a valid, defined and justifiable Background: Acute renal failure afterindication for the use of allogenic blood cardiac surgery is a known risk factor forproducts. Two audits at the UHWCM (1999 early mortality. This is of greater relevanceand 2001) showed that our usage of in our unit which has a higher incidence ofallogeneic blood was 90% and 65% for combined Coronary artery bypass graftprimary myocardial revascularization. In (CABG) plus Valve surgery (14.6%) thanaddition a National Audit showed our unit the UK national average (7.8%).to be the second highest user of red cells Objectives: Determination of risk factorsamong cardiac units audited in the UK. for acute renal failure requiringObjective To evaluate the effect of haemofiltration or dialysis following cardiacintraoperative cell salvage and transfusion surgery, and the outcome thereof.guidelines on autologous blood usage for Methods: Retrospective review of allfirst time coronary artery bypass grafts. patients (N = 1,817) who underwentPatients and methods We undertook a cardiac surgery between 1 January 2001prospective audit looking at 271 patients and 31 March 2003 (overall in-hospitalundergoing first time CABG (between mortality 3.8%). Patients who wereOctober 2002 and March 2003). 113 of receiving preoperative dialysis /these patients had intraoperative cell haemofiltration for acute or chronic renalsalvage (Group 1) whilst 156 did not failure were excluded (N = 19; mortality(Group 2). The status of two patients was 31.6%). The remaining 1,798 patientsunknown. were grouped according to requirement forResults In Group 1 (n= 113), 40 (35.5%) new postoperative haemofiltration. Riskhad allogeneic red cell transfusion while 68 factors identified by univariate analysis(60%) received no blood. The status of 5 were subjected to multivariate logisticpatients in this group was unknown (4.5%). regression analysis (SPSS version 11.0).In Group 2 (n=156), 97 patients(62%) were Results: Haemofiltration was required intransfused. The mean haemoglobin 82 patients (4.6%) postoperatively.values on admission to ITU were 10 for Categorical risk factors identified byGroup 1 and 9.4 for Group 2. The multivariate analysis included preoperativehaemoglobin on Day 6, when the vast creatinine > 200 μl/l, emergency surgery,majority of patients were discharged, was diabetes, post operative intra-aortic10.6 for Group 1 and 10.5 for Group 2. In balloon pump (IABP) or ventricular assistaddition, of the patients transfused red device (VAD), reopening for cardiac arrestcells, 70% received less than or equal to 2 or bleeding / tamponade (p < 0.0001). Tounits. Usage of FFP and Platelets in the a lesser extent, redo cardiac surgery,cell salvaged group (Group1) vs the non combined CABG + Valve surgery (p <cell salvaged group (Group 2) were 17% 0.03), and preoperative cardiogenic shockvs 14% and 20% vs 21% respectively. (p < 0.05). Numerical variables identifiedConclusion The adoption of transfusion included Euro score predicted mortalityguidelines and the use of intraoperative 10.23 % ± 0.54 % (standard error) versuscell salvage decreased the use of 1
  • 2. 4.66 % ± 0.08% in patients not requiring develop gut ischemia postoperatively. Thehaemofiltration, duration of mean age of this group was 69 years andcardiopulmonary bypass 151 ± 67 min. the male to female ratio was 3:1. Theversus 107 ± 40 min., and Parsonnet score diagnosis was made on post mortem in 3(Anova p < 0.0001). Poor outcomes of these cases. Eleven out of them wereassociated with post-operative coronary revascularisations, 2 were mitralhaemofiltration included increased in- valve replacements, 1 was an aortic valvehospital mortality of 61.0% versus 1.1% (p replacement and one was a double valve< 0.0001), postoperative atrial fibrillation, procedure. Two of the cases were donetracheostomy, pancreatitis (p < 0.008) and without CPB. Eleven patients hadpostoperative ventricular fibrillation (p < generalized bowel ischemia, while 5 had0.03). Reopening for cardiac arrest or localized necrosis involving the caecum inbleeding / tamponade was identified as a 3 and terminal ileum in 2 cases. The timerisk factor for haemofiltration and not a of presentation ranged from the first to the‘poor outcome caused by acute renal fourteenth post operative day and clinicalfailure’. In addition, identified risk factors features were varied. Eight patients hadfor mortality in patients needing post- been in a low output state requiringoperative haemofiltration include poor LV inotropes post operatively. The diagnosisfunction, COAD or asthma and cardiac was always clinical as no test is diagnosticprocedures excluding isolated valve of the condition.surgery (p < 0.05). Results Twenty-six laparatomies wereConclusions: Post cardiac surgery performed post cardiac surgery forhaemofiltration is required predominantly abdominal complications over the studyin higher risk patients with pre-existing co- period. Bowel ischemia was found in 13 ofmorbid factors – especially poor baseline these patients. Four laparatomies wererenal function and diabetes. Risk factors negative, while other pathologies werepossibly amenable to therapeutic found in nine patients. Three patients ofmodifications include duration of gut ischaemia were diagnosed at postcardiopulmonary bypass, need for mortem. Of the 16 patients with bowelpostoperative IABP / VAD and reopening infarction 11 patients were found to havefor cardiac arrest or bleeding / tamponade. extensive intestinal ischemia. Only 4 out of them underwent resection of the involved › š› š bowel and all of them died. In 5 patients localized ischemia was found involving the3. Gut Ischemia following Cardiac caecum in 3 and terminal ileum in 2. TheySurgery all underwent local resections and madeMr. S Hasan, Ms. J Gorden, Mr. C uneventful recoveries thereafter. FourRatnatunga, Mr. R Pillai, Mr. CT Lewis patients with suspected intestinalDerriford Hospital Plymouth John Radcliffe ischaemia had negative laparatomies overHospital Oxford. this period. This signifies over aggressiveBackground Intra - abdominal approach to the problem.complications occur in about 1% of the Conclusion We suggest that two separatepatients following cardiac surgery. Out of forms of bowel ischaemia followingall these complications gut ischemia is the cardiopulmonary bypass may exist. Themost dangerous and carries the highest first is a localized type, which has a goodmortality. prognosis if treated with prompt surgicalObjective We reviewed all patients who resection. The second is a generalizeddeveloped gut ischemia following cardiac type, which is related to post operative lowsurgery to get an insight into this difficult output and carries a poor prognosisproblem. regardless of the management.Material and Method We performed aretrospective and prospective clinical › š› šreview of over 4000 patients undergoing 4. Mid-term results of radial andcardiac surgery between November 1997 mammary arteries for complete arterialand April 2003. Sixteen out of them revascularisation in elective and 2
  • 3. nonelective coronary artery bypass 5. Surgical management of leftsurgery ventricular aneurysm: our experienceTMF Chowdhry, M Loubani, H Vohra, M Kalkat MS, Dandekar U, Kouchkolopos C,Galiñanes Smallpiece C, Parmar J, Ridley P, Satur C,Division of Cardiac Surgery/Department of Levine A.Surgery, Glenfield Hospital, Leicester North Staffordshire Royal Infirmary, StokeObjective: The aim of this study is to on Trentevaluate the use of the radial artery Background Coronary artery bypassalongside the internal mammary artery for surgery with or without aneurysmectomy iscomplete arterial revascularisation in used to treat patients with left ventricularelective and nonelective coronary bypass aneurysm (LVA). Analysis of surgicalgraft surgery. management of these patients was doneMethods: All patients undergoing coronary to evaluate if patients benefit from theseartery surgery alone over a four-year procedures.period with disease of more than one Methods Retrospective review of 91coronary artery were considered for consecutive patients who underwent LVAcomplete arterial revascularisation. Pre- repair at our hospital between March 1992operatively, all patients had an Allen’s test and December 2002. The information wason the non-dominant arm and a cut off retrieved from the case notes, prospectivepoint of ten seconds was used. database and follow up of patients.Results: 291 patients were revascularised Results 91 patients were identified whousing the radial and internal mammary underwent repair of LVA by variousarteries alone in Y-graft configuration. The techniques. There were 76 male patientsmean age of the study population was and mean age of 62 years (SD-7.5,62.4±8.8, with a male to female ratio of range-39 to 78 years). The location of221 to 70. Elective surgery was performed aneurysm was anteroapical (68%), apicalin 231 patients (79%); with nonelective (21%), posteroinferior (9.4%) andprocedures comprising a total of 61 anterolateral (2%). 23 % containedpatients (21%). The mean number of distal thrombus. 49% of patients had anginaanastomoses was 2.8 ± 0.8. There were CCS class III or greater, 54% hadseven peri-operative mortalities (2.4%), dyspnoea NYHA class III or greater andand 43 patients (14.7%) developed low 2% had ventricular arrythmias. 47% hadcardiac output syndrome requiring poor ejection fraction and 33 % requiredinotropes with or without intra-aortic urgent operations. Associated proceduresballoon pump. Forty patients (13.7%) included aortic valve replacement in 4developed postoperative supraventricular patients, mitral valve repair in one patientarrhythmias. There was no incidence of and bypass grafts in 88 patients . Only 3hand ischaemia or wound complications. patients had isolated repair of LVA. 79%After a mean follow up period of 35.4±12.5 patients underwent resection and linearmonths of 218 patients (74.9%), there plication of aneurysm, 16% plication alonewere one death 24 patients required and 5% had repairs by Dor`s procedure.readmissions for cardiac related causes. The in-hospital mortality was 11% andThe patients angina score were currently long term survival of 76% at a mean follow0.5 ±1.0 versus 2.6± 1.4 preoperatively. up of 39 months. In followed up patients,Conclusion: Total arterial out of 39 patients with preoperative NYHArevascularisation with the internal class III or higher, 32( 83%) were in classmammary and radial artery is associated II or lower and 42 of survivingwith a low rate of perioperative patients( 62%) were free of angina .complications and mortality, and can be Conclusion The repair of LVA issafely used in both elective and associated with acceptable mortality,nonelective bypass graft surgery with symptomatic improvement and long termexcellent clinical results. survival. The improvement is more › š› š pronounced in the patients with severer symptoms. 3
  • 4. › š› š 12.663±1.579% in controls to 7.945±0.9377% and 7.877±1.801%,6. Mitochondrial KATP channels, protein respectively (p<0.05). IPC also decreasedkinase C and p38MAPK are differentially apoptosis from 29.51±2.854% toinvolved in the anti-apoptotic effect of 14.22±3.046% (p<0.05) and this waspreconditioning with ischemia and with further reduced by CPC to 7.221±2.1%cardioplegia in the human myocardium. (p<0.05 versus IPC). The addition of 5-Hunaid A Vohra, Alan G Fowler, Manuel hydroxydecanoate, chelerythrine andGaliñanes SB203580 to both IPC and CPC resultedDepartment of Integrative Cardiovascular in an increase in necrosis whereas only 5-Physiology and Cardiac Surgery, hydroxydecanoate and chelerythrine leadUniversity of Leicester, UK. to a loss of the anti-apoptotic effect of IPCBackground The role of mitoKATP and CPC.channels, protein kinase C (PKC) andmitogen activated protein kinase Conclusion CPC is more efficacious than(p38MAPK) on apoptosis in the context of IPC in reducing apoptosis. MitoKATPmyocardial preconditioning is unknown in channels, PKC and p38MAPK are involvedhumans. in the inhibition of necrosis as a result ofObjectives We investigated the both IPC and CPC, whereas their anti-cardioprotective mechanisms of apoptotic effect may be mediated bypreconditioning with ischaemia (IPC) and mitoKATP channels and PKC only.with cardioplegia (CPC) in the humanmyocardium. › š› šMaterial and Methods Right atrialappendages were obtained from patients 7. ON-PUMP BEATING HEART MITRALat the time of coronary artery surgery. VALVE SURGERY FOR PATIENTS WITHFree-hand tissue sections (n=8/group) POOR LEFT VENTRICULAR FUNCTIONwere subjected to the following protocols: S GHOSH, C Alexiou, R S Jutley & S Kaerobic perfusion; 90min simulated Naiischaemia (SI) followed by 120min Dept of Cardiothoracic Surgery,reoxygenation (R) in Krebs Henseleit Nottingham City Hospital, Nottingham, UKHEPES solution (SI/R); IPC (5 min SI 5min Introduction Mitral valve surgery in theR) and CPC (with St Thomas’ cardioplegia presence of poor left ventricular function issolution No.2 for 5min followed by 5min associated with higher mortality. Wewashout), prior to SI. Inhibitors of mitoKATP describe one surgeon’s (SKN) evolvingchannels, PKC and p38MAPK (1mM 5- practice of mitral valve surgery on thehydroxydecanoate, 10µM chelerythrine beating heart using normothermicand 10µM SB203580, respectively) were cardiopulmonary bypass in this cohort ofadded for 10 min at the end of the patients.equilibration period and before the Methods Between January 2000 andinduction of ischaemia in the latter three December 2002, 23 patients (13 women,groups. Cell damage was measured by 10 men), age range 54-81 years (meancreatine kinase (CK) endpoint assay. Cell (SD) 68.6(4.8) years) with mitralapoptosis and necrosis were visualized in regurgitation and left ventricular ejectiontissue sections with fluorescent dyes using fraction <30% undergoing isolated repairFITC (TUNEL assay) and Propidium (n=4) or replacement (n=19) wereIodide, respectively. Quantification was investigated. All patients received maximaldone by laser fluorescence confocal drug therapy. 17 patients were New Yorkmicroscopy and NIH-Image software. Heart Association (NYHA) class III and 6Results CK leakage (IU/gram wet weight) were class IV. The mean duration ofwas significantly reduced to a similar follow-up was 17 ± 14 months and wasextent by IPC and CPC from 3.992±0.2895 complete for all survivors.to 2.475±0.186 and 2.567±0.25, Results The visual field of the on-pumprespectively (p<0.05). Both IPC and CPC beating heart was equal to that ofequally reduced necrosis from conventional valvular operation, and 4
  • 5. technical accuracy was not compromised. produce a fall in blood pressure of 30-50%The mean duration of ICU and hospital from the baseline. This shed blood wasstay was 2.4 ± 1.3 days and 8.9 ± 2.6 days heparinized and re-transfused after 60 minrespectively. Mean bypass time was 74.35 of hypotension. Then a laparotomy was± 14.8 min. 30-day mortality was performed and the infra-renal abdominalsignificantly lower (8.7%) when compared aorta clamped to render the lower limbsto mean Euroscore predicted mortality for ischaemic. This clamp was removed afterthis high risk group of patients (16.9%, 60min and 125I bovine serum albuminp<0.001). The medium term 1- and 2- year administered intravenously. The animalsurvival were 87% and 78% respectively. was allowed to reperfuse for a furtherNYHA class improved from 3.6 ± 0.5 to 1.9 60min and then a blood sample was taken± 0.7 at follow-up (p=0.037). and bronchoalveolar lavage performed.Conclusions On-pump beating heart This data was used to calculate a lungmitral valve surgery is a good surgical permeability index. We investigated fouroption in patients with poor left ventricular experimental groups: sham hypotensionfunction, and has advantages because plus sham ischaemia, hypotension only,conditions for the heart are more iscahaemia only, combined haemorrahgephysiological with a beating tonus than plus ischaemia group.with cardioplegia. Results: 6/6 (100%) of the sham group survived 180min compared to 5/6 (83%) in the hind limb ischaemia group and 4/6 › š› š (66%) in the hypotension only group. Only 6/13 (46%) in the combined haemorrhage8. Acute Lung Injury in a novel double plus hind limb ischaemia survived 180min.hit murine ischaemia/reperfusion The control group (n=4) had a Lungmodel. Permeability Index (LPI) of 5.2 ± 2.2Shrivastava V, Norman KE, Hellewell PG. compared to 14.2 ± 2.6 for the combinedCardiovascular Research Group, hypotension and hind limb ischaemiaUniversity of Sheffield. group (n=4).Background: Acute Respiratory Distress Conclusion: Mice exposed to a combinedSyndrome (ARDS) accounts for a insult of hypotension plus ischaemia havesignificant proportion of mortality after a higher mortality rate and have a highersuccessful ruptured abdominal aortic lung permeability index when compared toaneurysm (RAAA) repair when compared mice exposed to either of these eventsto elective repair of abdominal aortic alone.aneurysms (AAA). We hypothesize thatthe combination of two successiveischaemia/ reperfusion events predisposes › š› šthese patients to developing anoverwhelming inflammatory response. This 9. Off Pump Coronary Surgery Improvescan result in acute lung injury and to the Left Ventricular Function In Patientssubsequent development of ARDS. Undergoing Total Arterial Objectives: To establish a murine model Revascularization: A Randomised Trialthat involves two successive Using Cardiovascular Magneticischaemia/reperfusion insults similar to that Resonance Imaging and Biochemicalin patients undergoing emergency repair of Markersa ruptured abdominal aortic aneurysm. University of Oxford Clinical MagneticMaterials and Methods: C57BL/6 mice Resonance Research Centrewere anaesthetized with an intra-peritoneal Department of Cardiovascular Medicinemixture of ketamine, atropine and xylazine John Radcliffe Hospital, Oxford OX3 9DUaccording to weight. The trachea, carotid Background: There is biochemicalartery and jugular vein were cannulated to evidence that off pump coronary arteryallow for invasive blood pressure bypass grafting (OPCABG) reducesmonitoring, the withdrawal of blood and myocardial injury when compared to theadministration of drugs. Blood was use of cardiopulmonary bypass (ONCABG)withdrawn from the carotid cannula to but the functional significance of this is 5
  • 6. uncertain. We hypothesized that OPCABG surgery results in significantly better leftsurgery would result in reduced post- ventricular function early after surgery, butoperative reversible (stunning) and does not reduce the incidence and extentirreversible myocardial injury, as assessed of surgery-related irreversible myocardialby cardiovascular magnetic resonance injury.imaging (CMR).Methods: In a single centre randomised › š› štrial, 30 patients undergoing multi-vesseltotal arterial revascularization were 10. BEATING HEART TECHNIQUESrandomly assigned to OPCABG and 30 APPLIED TO COMBINED VALVE ANDpatients to ONCABG surgery. Patients GRAFT OPERATIONS REDUCESunderwent pre-operative and early (day 6) MYOCARDIAL DAMAGEpost-operative cine MRI for global left M Poullis, M Shackcloth, W Dihmis, Mventricular function assessment, and Pullan, B Fabricontrast enhanced CMR for assessment of The Cardiothoracic Centre, Liverpoolirreversible myocardial injury. Serial (pre- Objectives: Myocardial damageop, 1, 6, 12, 24, 48, 120 hours post-op) secondary to prolonged cross clamp timecardiac Troponin I measurements were is associated with significant morbidity andobtained and correlated with the CMR mortality. Combined valve and graft casesfindings. have longer cross clamp times secondaryResults: The two surgical groups were to procedure complexity. The larger thewell matched in terms of pre-operative number of grafts the longer the cross-(age, cardiopulmonary risk factors, pre- clamp time. Performing the grafts on aoperative medication use) and peri- beating heart with cardioplegic arrest foroperative (number of distal anastomoses, performing the valve replacement/repair isinotropic requirements) factors. The mean a way of reducing cross clamp time andpre-operative cardiac index was similar in may result in less myocardial damage.the two surgical groups (2.9 +/- 0.7 Methods: 1011 consecutive patientsONCABG; 2.9 +/- 0.8 OPCABG; p = 0.9). having either isolated valve or valve andPost-operatively, the cardiac index was graft operations were studied. Group A,significantly higher in the OPCABG group N=916 had cardoplegic arrest for all valve(2.7 +/- 0.6 ONCABG; 3.2 +/- 0.8 and bottom end anastomosis, group B,OPCABG; p = 0.04). The mean pre- N=95 had the bottom ends performed on aoperative ejection fraction was 62 % +/- 12 beating heart. Myocardial damage was% in the ONCABG group and 62 % +/- 11 assessed by measuring CKMB at 16 hours% in the OPCABG group (p = 0.9). Post- post operatively. Patients were stratified byoperatively this decreased to 59 % +/- 11 valve (mitral or aortic), and number of% in the ONCABG group and increased to grafts.65 % +/- 12 % in the OPCABG group (p = Results: An increase in aortic cross clamp0.03 for the change in EF). New time was associated with a significantirreversible myocardial injury was similar in increased CKMB release, p<0.001.incidence (36 % of ONCABG; 44 % of Increased CKMB release resulted inOPCABG; p = 0.8) and magnitude (6.3g increased ITU stay, p<0.001, increased+/- 3.6g ONCABG; 6.8g +/- 4.0g OPCABG; hospital stay, p<0.001, and an increase inp = 0.9) across the two groups. The hospital mortality, p<0.001. Performingmedian areas under the curve (AUC) grafts off pump prior to performing valvevalues for Troponin I release were replacement resulted in a significantlysignificantly larger in the ONCABG group reduced cross clamp time, p<0.001, and(182.0 µg/L) compared with the OPCABG myocardial damage as assessed by CKMBgroup (135.0 µg/L; p=0.02).There was only release, p<0.001 (See table 1)a moderate correlation Table 1.MVRAVRNo of graftsGrp A(N=662)Grp B(N=41)Grp A(N=254)Grp between theTroponin I AUC values and mean mass of Conclusions: Performing the grafts on anew myocardial hyperenhancement B(N=54)043343226148353944283394838367285840 beating heart followed by cross-clamping(r2=0.4; p=0.008). the aorta to perform the valveConclusion: In patients undergoing replacement/repair, reduces cross-clampisolated coronary artery grafting, OPCABG 6
  • 7. time, resulting in significantly less in the three different groups. Patients with myocardial damage. This in turn leads to a symptomatic carotid disease were shorter ITU and hospital stay, and a lower excluded. in-hospital mortality. Results The median number (interquartile range) of microemboli in the OPCABG, › š› š ONCABG and open-heart groups were 40 (28-80), 275 (199-472) and 860 11. Solid and Gaseous Cerebral (393-1321) respectively (P<0.01) (table1). Microembolisation During Off-pump, Twelve percent of microemboli in the On-pump and Open Cardiac Surgery OPCABG group were solid compared to Yasir Abu-Omar, Lognathen 28% and 22% in the ONCABG and open- Balacumaraswami, Paul M. Matthews, heart groups respectively. The proportion David W. Pigott, David P. Taggart of particulate microemboli was significantly Department of Cardiothoracic Surgery, higher in the on-pump groups compared to John Radcliffe Hospital, Oxford, UK OPCABG (P<0.05). In the on-pump Background Neurocognitive dysfunction groups, 24% of microemboli occurred remains a concern following cardiac during CPB, and 56% occurred during surgery using cardiopulmonary bypass aortic manipulation (cannulation, (CPB). Overt injury, usually a stroke, decannulation, application and removal of occurs in 3% of coronary artery bypass cross-clamp and / or side-clamp) (figure1). grafting (CABG) patients, while injury Figure 1: Gaseous and solid leading to cognitive impairment, only microembolisation during evident on detailed neuropsychological the course of procedures testing, occurs in up to 80% of all patients performed using CPB. soon after surgery and persists in a quarter of these at six months. Early postoperative Conclusions In summary, cerebral cognitive impairment correlates with later microembolisation remains a problem progression of cognitive decline and during cardiopulmonary bypass. This can impaired quality of life. Cardiopulmonary be minimised by performing off-pump bypass (CPB) can cause brain injury surgery with avoidance of aortic through several mechanisms, but manipulation. The ability to reliably intraoperative cerebral microembolisation discriminate between solid and gaseous is believed to be one of the most important microemboli has an important potential aetiological factors. role in targeting various prevention Objectives Using a new generation strategies to improve neurological outcome transcranial Doppler (TCD) ultrasound following cardiac operations, particularly (multifrequency, multirange TCD, de-airing following open procedures. Embodop, DWL), which can reject artefacts online and automatically › š› š discriminate between solid and gaseous microemboli, we compared the number 12. Coronary Surgery in patients with and nature of intraoperative microemboli in peripheral vascular disease: effect of patients undergoing on-pump and off- avoiding cardiopulmonary bypass pump cardiac surgical procedures. S Karthik 1, G Musleh 2, AD Grayson 1, Methods Bilateral continuous TCD DJM Keenan 2, DM Pullan 1, WC Dihmis 1, monitoring of the middle cerebral arteries R Hasan 2, BM Fabri 1 was performed in 45 patients (15 having 1 The Cardiothoracic Centre Liverpool, off-pump coronary artery bypass grafting United Kingdom. 2 Manchester Royal (OPCABG), 15 on-pump coronary artery Infirmary, United KingdomTable 1: bypass grafting proportion of gaseous and solid microemboli detected in Number and (ONCABG) and 15 open- heart procedures). All recordings were three patient groups. performed using a multirange, ProcedureHITSTotal multifrequency system to allow both Median [IQR]Gaseous (%)Solid measurement of the number and (%)OPCABG 40 [28-80]*88%12%**ONCABG 275 [199-472]*72%28%**Open-heart Procedures860 discrimination of the nature of microemboli [393-1321]*78%22%*** Comparison of the total number of microemboli between the 3 groups: P<0.01** Comparison of the proportion of gas and solid microemboli in the 3 groups: P<0.05 7
  • 8. operative hospital stays (p<0.001). However, the incidence of new atrial arrhythmia was higher (p=0.028). Results after adjusting for differences in case-mix (propensity score) are shown in the table below. Conclusions: Off-pump coronary surgery is safe in patients with peripheral vascular disease, with acceptable results. The incidence of post-operative stroke is substantially reduced when avoiding cardiopulmonary bypass in patients with PVD. Their in-hospital stay was also significantly shorter. Table 1: Number and proportion of Background: Due to the improvement in outcomes following coronary artery bypass › š› š grafting (CABG) that have been achieved over the last two decades, a greater 13. Does Off-Pump Coronary Grafting number of patients are being referred for Reduce Morbidity and Mortality CABG. Also, the patients undergoing Following Redo Surgery? CABG are more likely to be older with a Arun Srinivasan, AY Oo, AD Grayson, BM higher surgical risk. One group of patients Fabri who have been shown to have a The Cardiothoracic Centre-Liverpool, significantly higher risk of adverse events United Kingdom following CABG are patients with Background: Redo coronary surgery peripheral vascular diseases (PVD). (n=15)p ValueIn-hospital mortality0% with increased risk R Re-OPCAB (n=34)Re-ONCAB (CABG) is associated (0)20.0% (3)0.007Stroke0% 0 ( We (2)0.029CK-MB levels0 the of adverse outcomes. We hypothesised Objective: (0)13.3%aimed to quantify 0 (0 to 23)25 (0 to 34)0.225Acute renal failure0% (0)13.3% effect of avoiding cardio-pulmonary bypass to 540)600 mls (390 to 750)0.048Atrialprovide a ( 4 (2)0.029Blood loss in ICU402 mls (315 that off-pump CABG may fibrillation11.8% in patients with PVD undergoing CABG. potential benefit to redo patients. [25] ( 2 (4)33.3% (5)0.072Inotrope support2.9% (1)20.0% (3)0.044Mechanical ventilation4 hrs (2 to 6)6 hrs (4 Methods: Data was collected Methods: Between April 1997 and March 2002, t 3,771 consecutive 6 to 15)0.036Post-operative stay6 days (5 to 8)8 days (7 to 10)0.009 of routine clinical patients prospectively as part underwent CABG performed by five practice on 49 consecutive patients surgeons. 422 (11.2%) had PVD and of undergoing isolated redo coronary surgery these, 211 (50%) received off-pump performed by one surgeon between April surgery. We used multivariate logistic 1997 and March 2002. Thirty-four patients regression analysis to assess the effect of received redo off-pump CABG (Re- off-pump surgery on in-hospital mortality OPCAB) compared to 15 patients who and morbidity, while adjusting for treatment received redo on-pump CABG (Re- selection bias. Treatment selection bias ONCAB). Patient records were linked to was controlled for by constructing a the National Strategic Tracing Service, propensity score, which was the probability which records all deaths in the community, of receiving off-pump surgery and included to establish follow-up mortality. All analysis core patient characteristics. The C statistic was performed retrospectively. [71] for this model was 0.8. Results: There were no significant Results: Off-pump adjusted propensity score differences between Re-OPCAB and Re-Table 1: In-hospital outcomes patientsforwere more Off-pump (n=211)On-pump preoperative likely to have (n=211)Odds ratio (95% CI)p ValueIn-hospital mortality (%)4.95.00.98 (0.35 – renal ONCAB according to age, sex, ejection 2.75)0.98Myocardial Infarction (%)2.52.60.96 (0.24 – 3.92)0.96Stroke (%)1.05.60.09of disease, peripheral fraction, extent (0.02 – 0.50)0.005Atrial dysfunction, previous gastrointestinal arrhythmia (%)29.124.41.39 (0.84 – 2.30)0.21Renal failure (%)6.79.60.59 (0.26 – 1.34)0.21Re-explore for surgerybleedingless extensive disease. The vascular disease, diabetes, and (%)2.82.81.03 (0.27 – 3.95)0.97Sternal wound infection (%)1.62.70.50 (0.11 – renal dysfunction, respiratory disease and left internal mammarycomplications(%)1.02.50.28 (0.04 – 1.79)0.18Post-operative stay >7 days 2.33)0.38Gastrointestinal artery was used emergency surgery; variables suggested (%)43.457.00.46 (0.29 – 0.74)0.001 more in off-pump compared to on-pump cases (90.1% versus 82.9%; p=0.033). In for risk adjustment by the American the univariate analyses, off-pump patients College of Cardiology/American Heart were less likely to have a post-operative Association guidelines. Re-OPCAB stroke (p=0.007), and had shorter post- patients had fewer grafts (median: 2 8
  • 9. versus 4; p<0.001). Post-operative results via a thoracotomy is suited for anatomicalare shown in the table below. Follow-up correction but doesn’t facilitate surgery formortality was 5.9% (n=2) in Re-OPCAB associated abnormalities. Extra-anatomicalcompared to 40.0% (n=6) in Re-ONCAB bypass allows the surgeon to avoid friable(p=0.003). [75] collateral arteries, spinal chord ischaemia,Conclusions: This study suggests that the recurrent laryngeal and phrenic nervesfollowing redo CABG, early and late and the lymphatic vessels. Also anymortality, as well as morbidity, can be concurrent proximal pathology (aortic valvereduced by avoiding cardiopulmonary disease, aneurysm of the root, CABG) canbypass. [22] be addressed at the same operation. › š› š › š› š14. Ten year experience of adult repair 15. The initial experience with the theof coarctation of the aortaE Black1, A Goyal1, S Chatterjee1, M Shelhigh BioConduitTM No-ReactTMHamilton1, S Naik2, R Firmin1, M Hickey1 Valves – 46 patients1 Department of Cardiac Surgery, A. Sosnowski, M. Matuszewski, R. Janas,Glenfield Hospital, Leicester A. Szafranek. Glenfield Hospital,2 Department of Cardiac Surgery, LeicesterNottingham City hospital, Nottingham Background: Aortic root replacement isBackground Adult presentation of also performed in elderly patients or thosecoarctation of the aorta is rare. Severe who have contraindications forhypertension is a major cause of morbidity anticoagulation. Therefore, a reliableand mortality in these patients. For the tissue composite graft is necessary.surgeon, atherosclerotic vessels and well- Objective: To evaluate the short-termestablished collaterals present a surgical results of Shelhigh BioConduit use forchallenge. aortic root/ascending aorta replacement.Objectives We sought to review the South Material and methods: Between AugustTrent ten-year experience. 1999 and December 2002, 46 patientsMaterials & Methods A retrospective underwent implantation of Shelhighreview of all primary adult coarctation BioConduit. Mean age at surgery was 69repairs was performed. (34-83) years, mean Parsonnet score 18.7.Results Six patients, mean ages 28.8±13 The indications for the use of a compositeyr. were found. Mean preoperative systolic graft consisted of: aortic root/ascendingBP was 179±16mmHg. 3 patients had aortic aneurysm (39 cases), aorticbicuspid aortic valves. Tube-graft dissection (4 cases), severe calcification ofbypasses were used in 5 patients. the aortic root (2 cases), infectiveAnatomical repair was performed in the endocarditis with aortic root involvement (2first 3 patients via a thoracotomy. Of these, cases). Apart from aortic root replacement,one was by resection and end-to-end 33 patients underwent replacement ofanastomosis, two by bypass graft. ascending aorta, and 2 patients also aorticOperative strategy for the next case was arch replacement. Dacron tube graft waschanged in light of problems with collateral used in addition to BioConduit in 10 cases.haemorrhage with the pervious cases and 13 patients had associated proceduresliterature reviews. Extra-anatomical bypass (CABG, MVR). There were 6 redousing cardiopulmonary bypass was operations. 3 patients underwentperformed in the next 3 cases. 2 of these emergency or salvage procedures.patients also underwent AVR, one in In 17 patients the distal anastomosis wascombination with a root replacement. Post- performed using the open technique.operative systolic BP was reduced to130±18.7mmHg (p=0.002 cf. preop.) at Mean CPB XC Circ. 30-day valve size time time arrest mortalitydischarge. (mm) (min) (min) timeConclusions Correction of the coarctation (min)significantly reduced systolic BP. Approach 25 +/- 2.2 177 +/- 122 +/- 32 +/- 16 7 (15%) 9
  • 10. 90 43 later mortality by male sex (p=0.03) and poor LV (p=0.01).Results: The early mortality was 15%, CONCLUSIONS Correction of TR with anmostly due to acute heart failure; one annuloplasty band in these severelypatient died of uncontrollable bleeding due diseased patients is readily achieved. Weto acute dissection with re-entry in believe that it is now necessary todescending aorta. One patient had a establish a randomised trial to determine ifstroke, and one a TIA. One patient had to the best treatment for these patients.be re-explored for bleeding. At early follow Better preoperative guidelines might aidup 75% of survivors were NYHA I, 21% - patient selection and encourage correctionNYHA II, 4% - NYHA III. The mean of moderate TR.pressure gradients in early TTE were 5-15mm Hg regardless of valve size (Fig. 1), › š› šwith no or a trace of AR. 17. ADJUNCTIVE ULTRASOUND › š› š EXPOSURE (USE) ENHANCES GENE DELIVERY TO VASCULAR SMOOTH16. Tricuspid Valve Repair for ModerateTricuspid Regurgitation MUSCLE CELLS (VSMC) IN-VITRO,E Black, G Doukas, A Szafranek, A AND IN EX-VIVO AND IN-VIVOSosnowski, T Spyt PORCINE SAPHENOUS VEIN (SV).Glenfield Hospital, Leicester, United Enoch Akowuah1, Caroline Gray1, SheilaKingdom Francis1, Thierry Bettinger2, Axel Brisken3,BACKGROUND The need for surgical David Crossman1, Christopher Newman1.correction of moderate functional tricuspid Cardiovascular Research Group,regurgitation (TR) remains uncertain. University Sheffield1, Bracco Research,Some correct the left-sided valvular lesions Geneva2, PharmaSonics Inc, CA, USA3.only. Furthermore, there are no clear Background: Viral gene delivery isguidelines in the literature regarding efficient but progress to human studies istricuspid assessment. hampered by concerns over safety. Non-OBJECTIVES It has been our policy to viral alternatives whilst safe are relativelyrepair at least moderate TR. We sought toreview the affect of this policy prior to more less efficient. We assessed the hypothesisformal studies of correction of TR. that USE could mediate transfection ofMATERIALS & METHODS We reviewed reporter genes, and the therapeutic geneall patients who underwent tricuspid valve TIMP 3, in VSMCs, organ cultured SV,repair in addition to other corrective and in-vivo SVG using a new generation ofsurgery between June 1998 and echocontrast microbubble agents, BR14.September 2001. TR was graded 1 to 4 We compared USE and viral transgenewith trans-thoracic and or trans- expression.oesophageal echo. Method: VSMC were transfected withRESULTS 77 patients, 48% (37) male with Lac-Z, eGFP, luciferase (luc) or TIMP 3a median (IQR) age of 66 (58-84) were plasmid ± 1MHz USE for 60s in thefound. Repairs were with either Cosgrove- presence of BR14, or with theEdwards or St.Jude bands (median (IQR) corresponding recombinant adenovirus atsize 34 (32-38) mm). Additionalprocedures were 12 CABG, 3 AVR, 36 300PFU/cell. Organ cultured SV wasMVR/r, 12 AVR+MVR and 15 MVr+CABG. transfected with luc plasmid ± 100mmHgBypass time was 120±47.4mins and cross- non-distending static pressure for 5 min ±clamp time was 69.2±35.4mins. 30 day subsequent USE; In in-vivo experiments, PRIVATEEuroSCORE (median(IQR)mortality was 8% (5/60). These patients 5 all (2-14) porcine SV was transfected by intraluminalhad MVR/r, pressure (mean ±stdev) Mortality Systolic PA 2 had additional AVR. 55.8±14.8mmHg instillation of luc or TIMP 3 plasmid ± Grade of preop. TR (median(IQR)) 3 (3-4) 0 (0,1)* USE with BR14 and implanted as anover a of postop. TR (median(IQR)) Grade median follow up of 8 months (3-29)was 15% (9/60). 30-day mortality was NYHA preop. (median(IQR)) 3 (3,4) interposition graft to the carotid artery.significantly affected by age> 75(p=0.05) NYHA postop. (median(IQR)) 1 (1,2)* Samples were analysed for reporter gene*=p<0.001 10
  • 11. and TIMP 3 expression at 48h (VSMC in- 3 Department of Cardiovascular Medicine,vitro) or 72h (intact SV ex-vivo and in-vivo) University of Oxford.by luminometry, X-gal staining or western Background Radial artery conduits forblotting. coronary artery bypass grafting have a Results: USE with BR14 enhanced luc tendency to vasospasm and an early failure rate of up to 10%. Topicalexpression in VSMC by 3000-fold antispasmodics are widely used to preventcompared to DNA alone (1.2±0.18x106 vs vasospasm. Extensive studies have been0.4±0.05 x103 light units (LU)/mg cell conducted to measure the duration ofprotein; p<0.001, n=4); the number of Lac- action of such agents using in vitro (organZ positive cells was also markedly bath) methods. However their duration ofincreased (4.7±0.9 vs 0.1±0.1%; p<0.01, action in vivo is unknown.n=3). Static pressure alone did not increase Objective We compared the duration ofluc expression in intact SV compared with action of two topical antispasmodic agentsDNA alone (2.6±3 vs 2.3±4 x104 LU/g using the mouse aortic interposition grafttissue weight). In contrast, the enhanced luc as an in vivo model.expression after USE alone was further Methods 2mm abdominal aorticincreased using static pressure followed by interposition grafts were performed in 36USE (from 44.7±14 to 147 ±36 x104 LU/g; male C57BL6 mice. Donor aortic segmentsp<0.05 for these comparisons, n=6). In- were incubated for 15 minutes with either phenoxybenzamine (PB, 10?M),vivo gene expression after ex-vivo verapamil/nitroglycerin solution (VG, 30?Mtransfection of SV with plasmid followed each) or buffer (Control) immediately priorby USE was enhanced by 20-fold relative to grafting. The animals were recoveredto naked plasmid alone (6±1.5 vs 0.3±0.1 and then sacrificed at 2, 6, 12 and 24x103 LU/5mm of graft). In-vitro transgene hours after surgery (n=3 animals at eachexpression of lac-z, eGFP and TIMP 3 after time point) to enable the grafts to beadenoviral transfection was significantly harvested for evaluation in organ bathhigher than after USE transfection. studies. Segments studied at 0 hoursConclusion: These data provide proof-of- remained ungrafted. Contraction to 60mMconcept of USE enhanced transgene KCl and cumulative dose responses toexpression in VSMCs and in-vivo SVG. phenylephrine (PE, 1nM-10?M) wereThough expression levels are less than measured in each segment.those observed after viral transfection, the Results The figure shows responses to 10?M PE relative to KCl contraction indata lends further support to the concept of individual segments at each time point.USE assisted gene delivery. Data are mean ± S.E.M. Responses to PE were abolished up to 16 hours post- › š› š operatively in PB pre-treated grafts. In contrast, the effects of VG were lost within only 2 hours. Asterisks indicate significant difference (p<0.05) from controls, by a two tailed unpaired students t-test. Conclusions Phenoxybenzamine pre-18. Novel use of a mouse model to treatment of vascular grafts causesassess in vivo duration of action of reduced ?-adrenergic vasoconstriction fortopical antispasmodic agents. up to 16 hours in vivo.Shafi Mussa1, Tash Prior2, Nick Alp3, Verapamil/nitroglycerin pre-treatment failsKathryn J. Wood2, David P. Taggart1, and to prevent vasoconstriction in vascularKeith M. Channon 3. grafts even 2 hours after resumption of1 Department of Cardiothoracic Surgery, blood flow. The mouse aortic interpositionJohn Radcliffe Hospital, Oxford. graft model is a useful technique to assess2 Nuffield Department of Surgery, University in vivo duration of action of establishedof Oxford. and novel topical antispasmodics. Measurement of duration of action of antispasmodic agents using exclusively in 11
  • 12. vitro methods should be interpreted with compared to non-LMS coronary disease.caution. This finding suggests that widespread vascular elasticity defects may play a role › š› š in the development of LMS disease and be responsible for the higher incidence of19. Stenotic Disease Of The Left Main graft failure and cardiac deaths observedStem Is Associated With Reduced in this condition.Elasticity Of Extra-Cardiac VesselsKotidis K, Hadjinikolaou L, Galinanes M › š› šDepartment of Integrative CardiovascularPhysiology and Cardiac Surgery, 20. Use of Potassium Channel OpenersUniversity of Leicester To Prevent Spasm In The Radial Artery 1AIMS: To investigate whether the elastic Michael J Shackcloth, 1,2Alan R Conant , 2properties of medium size extracardiac Alec WM Simpson, and 1Whalid C Dihmis 1arteries are related with the distribution of The Cardiothoracic Centre, Liverpoolcoronary artery disease. NHS Trust, Thomas Drive, Liverpool, L14METHODS: the internal thoracic arteries 3PE, UK 2(ITA, n=53), long saphenous veins (LSV, Dept of Human Anatomy and Celln=38) and radial arteries (RA, n=35) from Biology, University of Liverpool, L69 3GE74 patients undergoing coronary surgery UK.were used in organ baths to determine Objectives: With the increased usage oftheir compliance, distensibility and the radial artery (RA) in coronary arteryincremental elastic modulus (iEmod). bypass graft surgery, the prevention ofTwenty-four patients had left main stem arterial spasm has become an important(LMS) disease and 50 non-LMS coronary priority for surgeons. The potassiumdisease. channel opener nicorandil has been shownRESULTS: the ITA from patients with LMS to relax the radial artery in vitro. Nicorandilpresented significantly lower compliance also stimulate nitric oxide production,(-17%) and distensibility (-18%) and which may be the mechanism of action bysignificantly higher iEmod (19%) at 80 which it relaxes the radial artery. WemmHg than ITA from patients with non- investigated the effect of the reversibleLMS disease. RA from patients with LMS potassium channel opener pinacidil andpresented higher iEmod (50%) at 40 the irreversible potassium channel openermmHg than RA from patients with non- minoxidil on radial artery segments.LMS disease. Furthermore, LSV from Methods: Sections of RA excess topatients with LMS had reduced compliance surgical need were obtained from theatre,(-45%), reduced distensibility (-40%) and with fully informed patient consent. Inincreased iEmod (34%) at 40 mmHg vitro, using an organ bath, segments of RAcompared to those with non-LMS disease. were contracted with KCl at 90mM and 30mM and 10nM endothelin-1 or 100nM angiotensin II. The ability of minoxidil sulphate to either prevent contraction or relax sections of precontracted RA was tested. The presence of functional potassium channels was confirmed by pinacidil-induced relaxation, which was reversed by the potassium channel blocker, glibenclamide. Results In RA precontracted with 30mM KCl (p<0.05) and 10nM endothelin 1 (p<0.05), pinacidil caused a significant decrease in tension when compared withCONCLUSIONS: LMS coronary disease is controls. Pinacidil failed to reverseassociated with significantly reduced contraction induced by 90mM KCl. Theelasticity of extracardiac arteries and veins observed pinacidil-induced relaxation was 12
  • 13. fully reversed by glibenclamide, replacement with or without replacement ofdemonstrating the presence of functional ascending or descending aorta.potassium channels. Minoxidil however, Emergency operation for aortic dissectionfailed to either reverse established was performed in one hundred and eightcontractions or significantly inhibit (36%) patients.contractions to any of the agonists used. RESULTS: The overall early mortality wasConclusions The reversible potassium 11%(34). Comparison of the resultschannel opener pinacidil causes relaxation between the high volume (133 patients)of the RA in vitro, demonstrating the and low volume surgeons (n=6, range 6 topresence of functional potassium 56 patients) are shown in Table1. Thechannels. However, the irreversible patient profile in both the groups werepotassium channel opener minoxidil failed similar, however, a significantly higherto have any measureable effect. Whilst number of aortic arch replacements werevasodilatation has been recorded in performed by the high volume operator.humans the lack of effect in RA may be Apart from post-operative renal failure nodue to the expression of a potassium other significant differences between thechannel subtype insensitive to minoxidil. two groups were observed. CONCLUSION: Elective surgery of the ›š › š ascending aorta/arch was associated with low mortality. Triggerlimited differences were TOnly TypeTotal (% of triggers)Systolic Blood T ( P Pressure <90mmHg4855%Respiratory Rate <8 4 5 identified both with pm00%Oliguria<30mls/hr1315%Pulse <40 o or >30 respect to the case 1 1 P 0 O <21. Early outcome of surgery of the profile and early clinical 910%Oxygen These or >130 bpm outcomes. Saturation o 1Ascending Aorta/Arch: Is there a data suggest,<90%1720% <that1appropriate techniques 2relationship with caseload? disseminated within a group of surgeons,P Narayan, M Caputo, B Mahesh, H is an effective and practical method ofAlwair, GD Angelini, AJ Bryan. service provision.Bristol Royal InfirmaryBACKGROUND: The relationship betweencaseload and early outcome remains a › š› šsubject for debate in cardiac surgery ingeneral. Surgery of the thoracic aorta is an 22. An Early Warning Indicator System Table of specialist expertise within the adultarea 1 Improves Patient Outcome After Adult O OutcomeTotalPercentageResolved3356%Re- Rcardiac surgical field. There is volume (n=167)p valueEarly Mortality (elective)4(5%)6(8%)0.1Early VariablesHigh volume (n=133)Low however, a Cardiac Surgery t triggered1322%ITU/HDU814%Theatre12%Other46% I T Oconflict (emergency)8(15%)16(14%)0.7Arch replacement21(16%)12 (7%)0.01Stroke6 (4%)9 (5%)0.3Renal Mortality between concentrating expertise Martin Kinsella, Sarah Banks, Racheland the provision of effective failure20(15%)37 (22%)0.1Re-op for bleeding12(9%)14 (8%)0.8Post op failure4(3%)15 (10%)0.01Respiratory emergency Cooper, Graham Coopercover.of stay study examines the application length This (days)14.8±11.413.2±10.90.3 Department of Cardiothoracic Surgeryof one organisational strategy over a ten Sheffield Teaching Hospitals NHS Trustyear period in a single centre. Background Early identification andOBJECTIVE: This study evaluates the appropriate treatment of ill patientsearly outcome of patients undergoing improves their outcomes. We introducedsurgery of the ascending aorta/ aortic arch an ‘Early Warning Indicator System’in a single institution and compares the (EWIS) to an adult cardiac surgical wardresults of a single high volume surgeon (C2) on 4/01/02. EWIS sets a series ofwith low volume operators. physiological parameters. Any patientMATERIALS AND METHODS: From 1993 whose parameters fall outside pre-till March 2003, 300 patients (aged 17 to determined values ‘trigger’. Once a patient80, median 62) underwent operations for has triggered there is an escalation ofreplacement of the ascending aorta/Arch. medical input until the parameter returns toOne hundred and fifteen (38%) patients the pre-determined range. A report card isunderwent composite aortic root completed for each patient who triggers.replacement, Thirty- two (10%) had aortic Objectives To assess how EWISvalve replacement with supracoronary functioned and whether or not it improvedinterposition graft, and one hundred and patient outcometwenty nine (43%) underwent replacement Material and Methods The report cardsof the ascending aorta only. Thirty- three and clinical notes of all patients who(11%) patients underwent aortic arch 13
  • 14. Table 1. 70 (106)triggered in PCT (n=15)SgT (n=14)Age (years)42 (33-51)49 (37-59)Gender (M/F)8/76/8Duration of IPPV (day)20 the period 1/4/02 to 31/7/02 However there has been no studies Mean5.7 (1.9)* (15-33)24 (12-28)Onset of stenosis (Weeks)comparing the surgical findings of stenosiswere reviewed and analysed. p p-0.005 PCT vs. .SgT70 (106)Distance below the vocal by percutaneous tracheostomyIntensive Care Unit records, Progressive caused cords (cm) M (95% CI)1.6 * (1.1-2.1) p p-0.002 PCT vs. SgT3.4 (2.3-4.5)Length of stenosis (cm) tracheostomy.Care Unit records and Hospital Episode with surgicalStatistics were(95% CI)3.0 to determineofthe M ( reviewed Objective: Compare the surgical findings (2.5-3.4) 2.7 (2.2-3.1)Diameter stenosis (mm)number of admissions to(2.0-6.6)4.7 number M (95% CI)4.3 C2, the (3.4-6.0)Tracho-oesphageal fistula2 casesNoneSurgeons’ commentsSurgery 4 of tracheal stenosis caused by surgicalof deaths on the ward andeasier more difficultSurgery number of tracheostomy and percutaneousreturns to Intensive Care Unit (ITU) for the tracheostomy.period 1/3/01 to 31/8/01 (prior to Materials and Methods: This was aintroduction of EWIS) and 1/3/02 to retrospective and prospective case notes31/8/02. The combined end-points of review study done on 29 patients referreddeath on the ward and readmission to ITU for surgical treatment of tracheal stenosiswere compared by chi-squared test. in periods between 1993 and 2003.Results In the 5 months from 1/4/02, 59 Patients were divided into two groups:patients caused 87 triggers. Thirteen percutaneous tracheostomy (PCT) andpatients (22%) triggered more than once. Surgical Tracheostomy (SgT). Location,The cause of the triggers are shown in the length, diameter, time of onset of stenosistable: and other tracheal injuries as well as possible precipitating factors in each groupThe outcomes of these patients were: were reportedThere was a significant reduction in death Results: The results are shown in table 1.on the ward and readmission to ITU Onset of stenosis was much quicker in thebetween 1/3/01 to 31/8/01 and 1/3/02 to percutaneous group [5.7 weeks Mean31/8/02; 32 of 458 admissions (6.98%) (1.9)] compared to the surgical group [70compared to 18 of 584 admissions (3.08%) weeks Mean(106)]. Also in the(p<0.001). percutaneous group the upper level ofConclusions EWIS is applicable to adult stenosis was closer to the vocal cords (1.6cardiac surgical practice. The majority of cm CI 95%-1.1-2.1) compared to thetriggers are for haemodynamic parameters surgical group (3.4 cms CI-2.3-4.5). In theand almost ¼ of patients trigger more than percutaneous group there were two casesone parameter or more than one time. We of tracheo-oesophageal fistula while thereobserved a significant reduction in death were none in the surgical group.and return to ITU following introduction of Conclusion: Tracheal stenosis caused byEWIS. percutaneous tracheostomy was subglottic in nature and was difficult to correct. › š› š › š› š23. Tracheal stenosis: A comparison ofstenosis caused by surgical 24. Conservative Management Oftracheostomy and percutaneous Estrogenic Oesophageal Perforationstracheostomy S. Hasan, ANA Jilaihawi, D PrakashG Raghuraman*, D Mullhi *, F Gao *J Hairmyres Hospital East Kilbride Glasgow.Marzouk#, Background: Oesophageal Perforations* Department of Anaesthesia & Intensive carry a high mortality and morbidity. ThereCare Medicine, #Department of Thoracic is.no consensus as to the best form ofSurgery, Birmingham Heartlands Hospital, management for this condition.Birmingham, B5 9SS, UK Objective: We reviewed all patients ofBackground: Tracheal stenosis following Iatrogenic Perforations seen at our centretracheostomy is considered as the most to assess the result of conservativecrucial long-term complications in recent managementliterature. (1) Although CT scan, MRI, Material and Method: We retrospectivelypulmonary function tests, endoscopy have reviewed all 26 patients with Iatrogenicall been used to diagnose this condition, Oesophageal Perforations seen at oursurgical findings are likely to be more centre over the last ten years, who were allaccurate and hence more reliable. managed conservatively. The mean age of 14
  • 15. the group was 59 years (16-92yrs).Fourteen out of them were females.Twenty-two (85%) were seen within 6hours of perforation. Seventeen patientshad non-malignant pathology while ninehad oesophageal carcinoma. The vastmajority of them(89%) resulted fromoesophageal dilatations. Chest pain wasthe commonest symptom that was presentin 85% of the cases. All patients weremanaged conservatively on a regimencomprising keeping them nil by mouth onintravenous fluids and broad spectrumantibiotics. Eight patients were kept onTPN while six required chest drains, 5 forpneumothoraces and 1 for pleuralcollection.Results: Twenty-two (85%) of the 26patients survived on this regimen and theirperforations healed. One patient requiredan early operation for uncontrolled sepsiswhile 5 patients had oesophagealresections, 4 for carcinomas and one for acongenital short oesophagus after theirperforations had healed. The overallmorbidity was low and these results werecomparable to those of operativetreatment in published series. Earlydiagnosis is crucial for the success of thisregimen and this is only possible if a highindex of suspicion is maintained.Conclusions: We conclude thatconservative management is the preferredtreatment for clean Iatrogenic Perforationof the oesophagus. 15
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