Perioperative stroke in coronary artery bypass patients

The use of both internal thoracic arteries for coronary revascularization increases the estimate of post-operative lower limb ischemia in patients with peripheral artery disease

Background

Patients with a history of peripheral arterial disease (PAD) undergoing coronary artery bypass grafting (CABG) exhibit higher rates of complications. There are conflicting data on the survival benefits for bilateral thoracic artery (BITA) grafting compared with left internal thoracic artery (LITA) CABG in patients with PAD. The aim of the study was to explore the influence of the use of BITA grafts vs. LITA for CABG on post-operative acute lower limb ischemia (ALLI) and main post-operative complications in patients with concomitant PAD.

Methods

We used a propensity-score (PS) based analysis to compare outcomes between the two surgical procedures, BITA and LITA. The inverse probability of treatment weighting PS technique was applied to adjust for pre- and intra-operative confounders, and to get optimal balancing of the pre-operative data. The primary outcome was the estimate of postoperative ALLI. Secondary outcomes included overall death and death of cardiac causes within 30 days of surgery, stroke and acute kidney disease (AKD).

Results

The study population consisted of 1961 patients. The LITA procedure was performed in 1768 patients whereas 193 patients underwent a BITA technique. The estimate of ALLI was 14% higher in the BITA compared to the LITA (p < 0.001) group. Thirty-day mortality, cardiac death, occurrence of stroke and AKI did not differ significantly between the groups.

Conclusions

The use of both ITAs led to a significant increase in ALLI. This result was most likely caused by the complete disruption of the ITA collateral providing additional blood supply to the lower extremities. Based on our data, BITA should be used with extreme caution in PAD patients. Further research on this topic is necessary to confirm our findings.

Long-Term Survival and Quality of Life After Hypothermic Circulatory Arrest in Aortic Surgery

BACKGROUND AND AIMS:

Hypothermic circulatory arrest carries a high risk of mortality and neurological complications. An important part of assessing surgical treatment is the evaluation of long-term survival and postoperative health-related quality of life.

MATERIAL AND METHODS:

In this prospective study, 30 patients undergoing hypothermic circulatory arrest during surgery of the thoracic aorta, and 31 comparison patients undergoing elective coronary artery surgery without hypothermic circulatory arrest were evaluated for long-term survival and health-related quality of life, using the RAND 36-Item Health Survey questionnaire. The results were compared to national age- and sex-matched reference populations of the chronically ill and healthy adults.

RESULTS:

After 4.6-8.0 years, available study (88%) and comparison (59%) patients were interviewed. The life expectancy was similar with 4- and 8-year survival of 90%, and 87% for the study group, and 94%, and 94% for the comparison group, respectively (log rank test, p = 0.62). The RAND-36 scores for study and comparison groups were congruent in all dimensions, describing physical, mental, and social domains. The study patients' health-related quality of life results were similar to the national reference population with chronic illnesses.

CONCLUSION:

After hypothermic circulatory arrest, patients undergoing surgery of the thoracic aorta achieve a similar long-term life expectancy and health-related quality of life as do patients undergoing coronary surgery without hypothermic circulatory arrest, and a health-related quality of life similar to the national reference population with chronic illnesses. These results justify operative treatment in this high-risk patient population.

The coagulopathy of cardiopulmonary bypass

There have been numerous publications on the coagulopathy of cardiopulmonary bypass (CPB). This review provides an introduction to the history and main components of current CPB circuits and summarizes the current knowledge of pathogenesis, prevention, and treatment of the CPB coagulopathy. It encompasses an overview of intra- and postoperative monitoring of coagulation with special emphasis on the near-patient testing, its main complications, and the transfusion support, while taking into account the major changes in the technology used and supportive care provided since its inception.

Impact of Prophylactic Amiodarone on Length of Hospital Stay, Stroke, and Atrial Fibrillation After Cardiothoracic Surgery

STUDY OBJECTIVE

To evaluate the effect of prophylactic amiodarone on length of stay (LOS), postoperative stroke, and postoperative atrial fibrillation (POAF).

DESIGN

Retrospective cohort study.

SETTING

Hartford Hospital, Hartford, Connecticut.

PATIENTS

Two thousand forty-six patients who underwent cardiothoracic surgery from February 1998-October 2003 (186 received amiodarone, 1860 were controls).

MEASUREMENTS AND MAIN RESULTS

Patients receiving any of the prophylactic amiodarone regimens used in the Atrial Fibrillation Suppression Trials (AFIST) I and II were matched (1:10 matching) for age, valvular surgery, history of atrial fibrillation, sex, beta-blocker intolerance, and preoperative digoxin therapy with patients not receiving amiodarone prophylaxis. The AFIST regimens consisted of oral amiodarone 6 g over 6 days and 7 g over 10 days, beginning on preoperative days 1 and 5, respectively, or a hybrid intravenous and oral loading regimen delivering amiodarone 7 g over 5 days. Mean+/-SD age of the patients was 68.9+/-9.8 years, 75% were men, and 21% had undergone valvular surgery. Patients receiving prophylactic amiodarone had a shorter LOS (8.6+/-6.0 days) than controls (11.6+/-14.0 days, p=0.003) and a reduced frequency of POAF (23.1% vs 29.9%, p=0.05). Frequency of stroke was not significantly affected (2.2% vs 2.7% in the amiodarone vs control groups, p=0.61).

CONCLUSION

Use of the prophylactic amiodarone regimens from the AFIST trials reduced LOS by 3.0 days and frequency of POAF by 22.7%.