Cause for concern?
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Anti-Bacterial Agents↗
Biomedical subjects
B M Fabri
Publications and source records attributed to B M Fabri.
A survey of current myocardial protection practices during coronary artery bypass grafting.
OBJECTIVE: To identify current myocardial protection strategies for coronary artery bypass grafting (CABG) across the UK and Ireland. METHODS: A questionnaire survey of 15 questions was sent to practising cardiac surgeons between June and October 2002. The list of surgeons was obtained from the Society of Cardiothoracic Surgeons of Great Britain and Ireland database and they were contacted by postal and electronic mail. RESULTS: 118 (73.7%) out of 160 surgeons responded to the survey. 61 (51.7%) perform CABG on-pump (ONCAB) while 10 (8.5%) practice off-pump CABG (OPCAB). 47 (39.8%) perform either depending on individual cases. Of the 108 surgeons performing ONCAB, 91 (84.3%) use cardioplegia while 17 (15.7%) use cross-clamp and fibrillation techniques. Of those using cardioplegia, 76 (83.5%) use blood cardioplegia, 15 (19.7%) use warm-blood and 60 (78.9%) use cold-blood cardioplegia. 15(16.5%) use crystalloid cardioplegia. Retrograde cardioplegia is used by 23 (25.2%). We find an interesting variation of practice in relation to specifics like warm induction, graft cardioplegia, hot-shot, single cross-clamp, hypothermia and venting procedures. An overwhelming majority of surgeons performing OPCAB use the Octopus stabiliser (n=44, 77.2%) with some others preferring the Genzyme system. Supplementary stabilisation is not commonly used. While most OPCAB surgeons use intracoronary shunts (n=51), some prefer blockers (n=9) and others use coronary sloops (n=36). Ischaemic preconditioning is not commonly practised. Several surgeons have changed their practice of myocardial protection in the last 5 years (n=45). CONCLUSIONS: This survey gives us an interesting insight into current myocardial protection practices in the UK and Ireland and may be useful for future reference.
Blood↗
Predicting blood pressure reactivity and heart rate variability from mood state following coronary artery bypass surgery.
STUDY OBJECTIVES: Coronary Artery Bypass Graft (CABG) surgery is a common and successful procedure for revascularisation. However, the experience can induce emotional reactions prior to and following surgery. This study aimed to document changes in blood pressure (BP) reactivity and heart rate variability (HRV) following CABG surgery, and to determine the impact of mood state, particularly anxiety and depression upon cardiovascular functioning. METHOD: Twenty-two patients preparing to receive elective, first time CABG surgery were recruited from The Cardiothoracic Centre, Liverpool, UK and psychologically assessed using the Hospital Anxiety and Depression Scale (HAD), Global Mood Scale (GMS) and the Dispositional Resilience Scale (DRI). BP and heart rate responses were also measured during four conditions: baseline response; laboratory session; ambulatory monitoring; and self-initialised recordings during the ambulatory period. In addition, HRV was measured for 12 h in conjunction with the ambulatory monitoring period. All measures were assessed 1 week prior to surgery and 2 months following surgery. RESULTS: A significant decrease in negative mood and an increase in positive mood were reported following surgery. Forty percent of patients were clinically anxious and depressed prior to surgery although this was reduced to 27% after surgery. Depression was the strongest independent predictor of pre-operative BP and HRV whilst anxiety was most significantly related to follow-up BP reactivity. DBP was most strongly predicted by mood state. CONCLUSIONS: These results suggest that patients with higher levels of anxiety and depression are at risk of reduced HRV and increased BP reactivity in response to mental stressors. The study also strongly suggests that current patient services should be expanded to acknowledge the role of psychological factors within clinical prognosis after CABG surgery.
Affect↗
Repair of post-infarct ventricular septal defect with or without coronary artery bypass grafting in the northwest of England: a 5-year multi-institutional experience.
OBJECTIVE: To present the 5-year experience of the northwest of England's surgical repair of post myocardial infarction (MI) ventricular septal defects (VSD). Our primary aim was to evaluate the effect of concomitant coronary artery bypass grafting (CABG) on mid-term survival and also to identify prognostic indicators. METHODS: A multi-centre regional observational study involving clinical data from 65 consecutive patients who underwent post MI VSD repair in the northwest of England between April 1997 and March 2002. Both prospective and retrospective collection of preoperative, operative and postoperative information was performed. Patient follow-up was performed by linking their records to the National Strategic Tracing Service database. Multivariate logistic regression and Cox proportional hazards analyses were used to identify independent risk factors for poor prognosis. RESULTS: Of the 65 patients included in the study, 42 (64.6%) underwent concomitant CABG with a median of two grafts. The majority of patients who had their coronary arteries grafted had multivessel disease (92.9%). Overall 30-day mortality was 23.1%. Predictors of poor prognosis included preoperative inotropes (P<0.001) and total occlusion of infarct related artery (P=0.03). The crude hazard ratio (HR) of mid-term mortality for concomitant CABG patients was 0.82 [95% confidence interval (CI) 0.38-1.78; P=0.62]. After adjustment for differences in patient and disease characteristics, the adjusted HR of mid-term mortality for concomitant CABG patients was 0.17 (95% CI 0.04-0.74; P=0.019). The adjusted freedom from death in the concomitant CABG patients at 30 days, 1, 2, and 4 years was 96.2%, 91.6%, 88.8%, and 82.8%, respectively, compared with 79.1%, 58.8%, 49.1%, and 32.2% for the non-concomitant CABG patients. CONCLUSION: These data provide evidence that concomitant CABG is significantly beneficial to mid-term mortality rates. We recommend that patients who present with post MI VSD who have multivessel disease should be routinely revascularised.
Aged↗
The effect off-pump coronary artery bypass surgery on in-hospital mortality and morbidity.
OBJECTIVE: Off-pump coronary artery bypass (OPCAB) surgery is being increasingly reported to show better outcomes compared to conventional on bypass grafting. We examined the effect of OPCAB on in-hospital mortality and morbidity, while adjusting for patient and disease characteristics, in four institutions in the North West of England. METHODS: Between April 1997 and March 2001, 10,941 consecutive patients underwent isolated coronary artery bypass surgery at these four institutions. Of these, 7.7% were performed off-pump. We used logistic regression to examine the effect of OPCAB on in-hospital mortality and morbidity after adjusting for potentially confounding variables. RESULTS: The crude odds ratio (OR) for death (off-pump versus on-pump coronary bypass grafting) was 0.48 (95% confidence interval, CI 0.26-0.92; P=0.023). After adjustment for all major risk factors, the OR for death was 0.59 (95% CI 0.31-1.12; P=0.105). Off-pump patients had a substantially reduced risk of post-operative stroke (0.6 versus 2.3%, respectively; adjusted OR 0.26 (95% CI 0.09-0.70; P=0.008) and a significant reduction in post-operative hospital stay. Other morbidity outcomes were similar in both groups. CONCLUSIONS: Off-pump coronary artery bypass incurs no increased risk of in-hospital mortality. In contrast, there is a significant reduction in morbidity in patients undergoing off-pump coronary bypass grafting when compared to that performed on cardiopulmonary bypass.
Aged↗
Antegrade cardioplegia pressure monitoring.
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Aorta↗
Gastroesophageal reflux and tracheobronchial contamination after cardiac surgery: should a nasogastric tube be routine?
Nasogastric (NG) tubes are routinely used in patients undergoing cardiac surgery. This randomized study was designed to assess gastroesophageal reflux (GER) without a NG tube (control) compared with a NG tube managed either by gravity drainage (gravity) or continuous low-grade suction (suction). Antimony pH probes were placed in the lower esophagus and trachea after induction of anesthesia in 51 patients, and pH was recorded every 5 s until the time of tracheal extubation. GER was defined as reversible decrease in esophageal pH to less than 4.0. No significant difference was found between groups in age, weight, gender, duration of postoperative ventilation, morphine use, or antiemetic use. All indicators of GER were seen more frequently in the gravity group compared with the two other groups (P < 0.001). One episode of sudden decrease in tracheal pH was observed in a patient in the gravity group, indicating tracheal aspiration, which was associated with delayed extubation and postoperative pneumonia. The absence of a NG tube is not associated with reflux, probably since the gastroesophageal sphincter remains competent. NG tubes are not routinely necessary for cardiac surgery in patients without risk factors for GER, and increase reflux risk if managed without low-grade suction.
Aged↗
Continuous warm versus intermittent cold blood cardioplegia for coronary bypass surgery in patients with left ventricular dysfunction.
Between October 1991 and March 1994, 108 consecutive patients with moderate to severe left ventricular dysfunction underwent non-emergency isolated coronary artery surgery under the care of one surgeon (A.R.). They were prospectively randomised to receiving either intermittent cold (Group 1-50 patients) or continuous warm (Group 2-58 patients) blood cardioplegia for myocardial protection. There were no significant differences in clinical outcome between the two groups, as judged by operative mortality, rates of perioperative myocardial infarction, the serum CKMB isoenzyme level at 2 and 18 h after operation, need for circulatory support, postoperative neurological deficit, or duration of hospital stay. Group 2 patients required significantly more potassium (68 vs 29 mmol, P < 0.001) to maintain diastolic arrest and also had higher serum potassium levels after removal of the cross-clamp (P < 0.001). However, sinus rhythm returned spontaneously with greater frequency (91.2% vs 45.8%, P < 0.001) in Group 2 patients. In conclusion this report suggests that retrograde continuous warm blood cardioplegia provides comparable myocardial protection to that achieved with retrograde intermittent cold blood cardioplegia in patients with moderate to severe left ventricular dysfunction undergoing isolated coronary artery surgery.
Aged↗
Evidence that continuous normothermic blood cardioplegia offers better myocardial protection than intermittent hypothermic cardioplegia.
OBJECTIVES: To compare transmyocardial ischaemia and oxidative stress, as well as non-infarction myocardial injury, in patients randomised to intermittent hypothermic cardioplegia or continuous normothermic blood-potassium cardioplegia. DESIGN: Prospective randomised trial. SETTING: Tertiary cardiac referral centre. METHODS: 24 patients undergoing elective coronary artery bypass surgery were randomised to hypothermic (13 patients, mean (SEM) age 59.5 (2.6) years) or normothermic (11 patients, mean (SEM) age 59.7 (3.3) years) cardioplegia. Transmyocardial oxidative stress and ischaemia were assessed by the difference in plasma concentrations of oxidised glutathione and lactate respectively, from samples taken simultaneously from the coronary sinus and aortic root. Blood samples were taken just before cross clamp application and at intervals up to 15 min after cross clamp release. Non-infarction myocardial injury was assessed by measurement of creatine kinase MB isoenzyme activity from peripheral venous blood taken 2 and 18 h after surgery. RESULTS: Intermittent hypothermic cardioplegia resulted in a significant increase in transmyocardial ischaemia (P < 0.001) and oxidative stress (P < 0.001). Evidence of significantly increased myocyte damage was also present (P < 0.01). No significant corresponding changes were present with normothermic cardioplegia. CONCLUSIONS: Normothermic blood cardioplegia seems to avoid significant changes in myocardial ischaemic status and consequent oxidative stress. This study provides direct evidence that normothermic cardioplegia offers enhanced myocardial protection compared with that of hypothermic cardioplegia. Certain subsets of patients may derive more benefit from normothermic cardioplegia, although it is unclear whether this would be the case for all patients.
Cardiopulmonary Bypass↗
The management of anticoagulation in patients with prosthetic heart valves undergoing non-cardiac operations.
Prosthetic valve thrombogenicity and bleeding complications associated with life-long anticoagulation are constant potential causes of morbidity and mortality following prosthetic valve implantation. The conflict between over- and under-anticoagulation is even more of a problem when other surgical interventions are required. Very few clinical trials have addressed this issue. We propose some guidelines based on the concept of risk-adjusted intensity of anticoagulation but stress the need for caution with interpretation of these recommendations.
Anticoagulants↗
Normothermic versus hypothermic coronary bypass surgery.
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Coronary Artery Bypass↗
Transmitral Doppler assessment of left ventricular diastolic function during coronary artery bypass surgery.
OBJECTIVE: To evaluate which Doppler transmitral velocity indices of left ventricular diastolic function change with alteration of left ventricular filling pressure. METHODS: Twenty-two patients undergoing coronary artery bypass surgery. The effect of fluid loading on indices derived from the transmitral Doppler waveform, recorded by a trans-oesophageal echocardiography, was evaluated using a generalised linear statistical model. RESULTS: E-wave maximum velocity, E-wave acceleration time and slope, E-wave deceleration slope, A-wave maximum velocity and E/A wave maximum velocity ratio showed significant changes after alterations in left ventricular filling pressure. E-wave deceleration time and E-wave maximum velocity/time velocity integral showed no significant change after fluid loading. CONCLUSION: Several commonly used Doppler derived indices of left ventricular diastolic function are significantly affected by changes in filling pressure of the left ventricle. This may limit the usefulness of the Doppler method for serial assessment of diastolic function when the left ventricular filling pressure has changed between assessments. Only the E-wave deceleration time did not show significant changes and might be a useful Doppler index for the serial measurement of left ventricular compliance but this needs to be confirmed with haemodynamic measurements.
Adult↗
A prospective randomised study of continuous warm versus intermittent cold blood cardioplegia for coronary artery surgery: preliminary report.
Between October 1991 and March 1993, 281 consecutive patients underwent non-emergency isolated coronary artery surgery under the care of one surgeon (A.R.). They were prospectively randomised to receive either intermittent cold (Group I-144 patients) or continuous warm (Group II-137 patients) blood cardioplegia for myocardial protection. There were no significant differences in clinical outcome between the two groups, as judged by operative mortality, rates of peri-operative myocardial infarction, blood loss, need for circulatory support, post-operative neurological deficit, or duration of intensive care or hospital stay. However, sinus rhythm returned spontaneously with greater frequency (91.2% vs 45.8%, P < 0.001) in Group II patients. There was greater transmyocardial oxidative stress in Group I patients, as evidenced by a significant rise in oxidised glutathione in coronary sinus blood on myocardial reperfusion. Also, the serum CKMb isoenzyme level 2 h post-operatively was significantly raised in Group I patients, although this difference had disappeared by the day after surgery. In conclusion this preliminary report suggests that continuous warm blood cardioplegia provides comparable myocardial protection to that achieved with standard hypothermic techniques in patients undergoing coronary artery surgery.
Coronary Angiography↗
Hyperkalaemia after warm heart surgery.
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Cardiac Surgical Procedures↗
Left ventricular free wall rupture after coronary artery surgery.
A patient who had undergone urgent coronary artery bypass grafting for unstable angina developed a fatal left ventricular free wall rupture in the early postoperative period. Heart rupture following surgical revascularisation has not been reported before.
Aged↗
Normothermic arrest with continuous hyperkalaemic blood: initial experience.
The requirement for hypothermia in myocardial protection has recently been questioned. Between October 1990 and May 1991, diastolic arrest was achieved using continuous perfusion with normothermic, hyperkalaemic blood in 257 consecutive patients undergoing cardiac surgery. The mean age was 59.8 +/- 9.3 years (range 28-84 years). Coronary artery surgery was performed in 210 patients, valve replacements in 18, combined procedures in 22, and 7 patients had miscellaneous procedures. Eleven patients (4.3%) had undergone previous cardiac surgery, and 65 (25.3%) required urgent or emergency operations. Hyperkalaemic blood (7-20 mmol/l) was delivered antegradely in 190 (72.8%) patients (mean aortic root pressure 60-80 mmHg), retrogradely in 62 (25.3%) patients (mean coronary sinus pressure less than 40 mmHg), and by a combined route in 5 (1.9%). Sinus rhythm returned immediately after removal of the aortic clamp in 235 (91.4%) patients. Weaning from bypass was achieved without circulatory support in 207 (82.5%) patients. Of 233 patients undergoing non-emergency coronary artery surgery, single valve or combined procedures, 11 died, giving an operative mortality of 4.7%. Of 155 patients with good left ventricular function requiring coronary artery surgery, 3 (1.9%) died. The in-hospital mortality for the group as a whole was 7.3%. Sixteen (6.2%) patients sustained perioperative myocardial infarctions; of these 6 died. We conclude that continuous, normothermic, hyperkalaemic arrest is a simple and safe method of myocardial protection. It may avoid the damage associated with hypothermia, ischaemia and reperfusion.
Adult↗
Early rupture of a saphenous vein graft.
Early rupture of a saphenous vein graft used for coronary artery surgery has not been previously reported. In a 69-year-old man having a third coronary by-pass procedure, one of the saphenous vein grafts ruptured on the 8th postoperative day. The other vein graft showed marked aneurysm formation at two sites. Histological examination of the ruptured graft revealed that this was due to a bacterial infection within the wall of the vein. Although he survived an emergency operation to control the haemorrhage and replace the ruptured graft, he died some days later of mediastinitis. It appeared that both the rupture of the graft and the ensuing mediastinitis were due to a primary infective process within the saphenous vein used for the graft.
Aged↗
Selective decontamination of the digestive tract in cardiac surgical patients.
OBJECTIVE: To test the hypothesis that selective decontamination of the digestive tract improves outcome in cardiac surgical patients. DESIGN: Prospective, consecutive, controlled trial over two 4-month periods. SETTING: Eight-bed, open-plan postcardiac surgery ICU. PATIENTS: All patients undergoing cardiac bypass surgery were eligible. Patients requiring endotracheal intubation for greater than 4 days were included in the analysis. In the initial 4 months, 12 (8.5%) of 141 patients required greater than 4 days of intubation. These 12 patients were not treated with selective decontamination of the digestive tract. We therefore used these patients as the control group. In the second 4-month period, 12 (6.6%) of 180 patients were treated with selective decontamination of the digestive tract and formed the study group. MAIN OUTCOME MEASURES: The primary measure was mortality. Secondary measures included oropharyngeal decontamination and the presence of lower airway infection. INTERVENTIONS: Cephradine prophylaxis. The study group received every 6 hrs 4 mL orally and 20 mL intragastrically a suspension of antimicrobial agents (tobramycin 80 mg, polymyxin E 100 mg, amphotericin B 500 mg), starting on postoperative day 1. The control group did not receive any oral antimicrobial agents. RESULTS: Mortality rate was significantly (p less than .05) reduced from eight (66%) of 12 patients in the control group to two (16.7%) of 12 patients in the selective decontamination of the digestive tract group. No differences in oropharyngeal decontamination or lower airway infection rates between the two groups were found. CONCLUSIONS: There is a reduced mortality rate in patients receiving selective decontamination of the digestive tract. However, the reader should recognize the small sample size studied. A simple suspension of the antimicrobial agents failed to rid the oropharynx of bacteria.
Administration, Oral↗