Preoperative continuation of aspirin before isolated heart valve surgery and postoperative bleeding and transfusion: a single-center retrospective study

BACKGROUND

The risks and benefits of preoperative aspirin continuation in patients undergoing isolated heart valve replacement surgery are unclear. We investigated the effect of aspirin continuation on the risk of bleeding and transfusion in these patients.

METHODS

In this single center, retrospective study, among 474 adult patients who underwent isolated heart valve surgery between April 2013 and June 2018, 269 continued aspirin within 5 days before surgery (aspirin group) and 205 patients did not take or stopped aspirin no later than 5 days before surgery (non-aspirin group). The chi-square test, the Mann-Whitney U-test, and the Student's T-test were used to compare data between the groups. Univariate and Multivariate logistic regressions were used to assess crude and adjusted relationships between outcome and exposure.

RESULTS

The primary outcome, red blood cell (RBC) transfusion, occurred in 59 patients (22%) of the aspirin group and in 24 patients (12%) of the non-aspirin group (p = 0.004). After adjustment for confounding factors, continuation of aspirin was no longer associated with RBC transfusion (aOR1.8;95%CI,0.98-3.2;p = 0.06). The amount of allogenic blood products, the incidence of surgical re-exploration for bleeding, the volume of re-transfused cell-saved blood, and the cumulative chest tube drainage during the first 24 postoperative hours were similar between groups.

CONCLUSION

Preoperative continuation of aspirin in patients undergoing isolated heart valve surgery is neither associated with a higher incidence of RBC transfusion, nor with larger perioperative blood loss, or more frequent surgical revision for bleeding.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT05151796).

Cardiac Biomarkers and Prediction of Early Outcome After Heart Valve Surgery: A Prospective Observational Study

OBJECTIVES

Circulating cardiac biomarkers may improve the prediction of long-term outcomes after cardiac surgery. The authors sought to assess if cardiac biomarkers also help better predict short-term morbidity.

DESIGN

Prospective observational study.

SETTING

Single academic hospital.

PARTICIPANTS

A total of 250 patients undergoing aortic or mitral valve surgery with or without associated coronary artery bypass grafts.

INTERVENTION

None MEASUREMENT AND MAIN RESULTS: Relationships between preoperative plasma concentrations of four cardiac biomarkers (sST2, Galectin-3, GDF-15, and NT-proBNP) and postoperative outcome were assessed using logistic regressions and Cox proportional hazards models. The primary outcome was a composite of 30-day mortality, an inotropic support longer than 48 hours and an initial length of stay in the intensive care >five days. Secondary outcome measures were postoperative acute kidney injury, inotropic support duration, lengths of intensive care unit and hospital stays, and 30-day and one-year mortality. No association was observed between any of the four cardiac biomarkers and the primary outcome. The preoperative levels of Galectin-3 (hazard ratio = 1.2; p < 0.001) and sST2 (hazard ratio = 1.01, p < 0.001) were significantly associated with one-year survival, and their addition to the EuroSCORE II significantly improved the prediction of one-year mortality (p < 0.001). Similarly, Galectin-3 was associated with postoperative acute kidney injury (odds ratio = 1.15, p = 0.001) and improved the prediction of this complication when added to the EuroSCORE II (p = 0.002).

CONCLUSIONS

These results suggested that the ability of cardiac biomarkers to predict short-term outcome after cardiac surgery, though of interest, appears limited. Conversely, cardiac biomarkers may have the potential to refine the prediction of long-term outcome. Admittedly, all positive results were obtained on secondary outcomes and must be regarded with caution.

Clinical course and challenging management of early COVID-19 infection after heart transplantation: case report of two patients

BACKGROUND

There are limited data on Coronavirus disease 2019 (COVID-19) in solid organ transplant patients, especially in heart transplant recipients, with only a few case reports and case series described so far. Heart transplant recipients may be at particular high risk due to their comorbidities and immunosuppressed state.

CASE PRESENTATION

This report describes the clinical course and the challenging management of early COVID-19 infection in two heart transplant recipients who tested positive for the SARS-CoV-2 virus in the perioperative period of the transplant procedure. The two patients developed a severe form of the disease and ultimately died despite the initiation of an antiviral monotherapy with hydroxychloroquine coupled with the interruption of mycophenolate mofetil.

CONCLUSIONS

These two cases illustrate the severity and poor prognosis of COVID-19 in the perioperative period of a heart transplant. Thorough screening of donors and recipients is mandatory, and the issue of asymptomatic carriers needs to be addressed.

Lipomatous hypertrophy of the interatrial septum: the typical echographic aspect is worth being known

A 65-year-old man was scheduled for an on-pump coronary artery bypass graft procedure because of a three-vessels coronary artery disease. A right atrial mass appended to the interatrial septum was discovered during intraoperative transoesophageal echocardiography. Therefore, the right atrium was opened. Gross examination revealed a fatty lesion of the interatrial septum. A biopsy was performed before the atrium was closed. A histological diagnosis of lipomatous hypertrophy of the interatrial septum was made. Lipomatous hypertrophy of the interatrial septum is a mass of adipocytes infiltrating the interatrial septum. The aspect of "dumbbell" produced by the sparing of the Fossa Ovalis is typical. The lesion is benign and remains asymptomatic most of the time although it can be responsible for cardiac arrhythmias or circulatory obstruction. The typical echographic aspect should be known to avoid unnecessary surgical resection.

Comparison between two intraoperative intravenous loading doses of paracetamol on pain after minor hand surgery: two grams versus one gram

BACKGROUND

Paracetamol (acetaminophen) is widely used for postoperative analgesia at a recommended dose of 1 g every six hours in adult patients. Increasing the loading dose to 2 g was suggested to improve immediate postoperative analgesia without increased toxicity in healthy adult patients. We tested the hypothesis that a loading dose of 2 g of intravenous paracetamol results in better postoperative analgesia after surgery as compared with a dose of 1 g.

METHODS

Sixty adult patients scheduled for minor hand surgery under intravenous regional anaesthesia were randomized into two groups. The first group received 1 g of intravenous paracetamol before surgery while the second group received 2 g. Verbal numeric pain score, analgesic consumption, first night sleep quality, and patient's satisfaction were recorded during the first 24 hours.

RESULTS

Verbal numeric pain scores during the first 24 hours after surgery were significantly lower in the 2 g paracetamol group as compared to the 1 g paracetamol group. No differences were found between the two groups with regard to rescue analgesic consumption, sleep quality and patient's satisfaction.

CONCLUSIONS

An intraoperative loading dose of 2 g paracetamol improves postoperative analgesia after minor hand surgery as compared to 1 g paracetamol.

Cerebral subarachnoid blood migration consecutive to a lumbar haematoma after spinal anaesthesia

We report the case of a woman who received spinal anaesthesia for peripheral vascular surgery of the lower limbs and subsequently developed a spinal subarachnoid haematoma. Interestingly, low back pain was the only symptom of this spinal subarachnoid haemorrhage. During the following days, blood migrated from the spinal haematoma towards the cerebral subarachnoid spaces. The patient presented with stupor, nausea and vomiting that resolved within 2 weeks with conservative treatment.

The use of pre-operative intrathecal morphine for analgesia following coronary artery bypass surgery

With the emergence of rapid extubation protocols following cardiac surgery, providing adequate analgesia in the early postoperative period is important. This prospective randomised double-blind study investigated the benefits of pre-operative intrathecal administration of low dose morphine in patients undergoing coronary artery bypass graft surgery. Postoperative analgesia, pulmonary function, stress response and postoperative recovery profile were assessed. Thirty patients were allocated into two groups, receiving either 500 mug of morphine intrathecally prior to anaesthesia and intravenous patient-controlled analgesia with morphine postoperatively following tracheal extubation, or only postoperative intravenous patient-controlled analgesia. In the intrathecal group, the total consumption of intravenous morphine following surgery was significantly reduced by 40% and patients reported lower pain scores at rest, during the first 24 h following extubation. Peak expiratory flow rate was greater and postoperative catecholamine release was significantly lower. Patients in the control group had a higher incidence of reduced respiratory rate following extubation.

Thromboprophylaxis in microsurgery

Microsurgical free tissue transfer has become a gold standard in a wide range of clinical situations. Thrombosis at the anastomotic site is not only the most common cause of failure of microsurgical operations, but it is also one of the factors resulting in microcirculatory intravascular thrombosis in free flaps. All conditions of thrombus formation, defined by Virchow in 1856, are encountered in free flap surgery. This literature review concerns the problem of thromboprophylaxis in microsurgery. All citations published this last ten years (1996-2005) concerning this problem are noted. Data are confronted with other specialties, particularly vascular surgery, or with large retrospective studies. Protocol used in our institution is presented at the end of this lecture.

Epidural Levobupivacaine 0.1% or Ropivacaine 0.1% Combined with Morphine Provides Comparable Analgesia After Abdominal Surgery

Ropivacaine appears attractive for epidural analgesia because it produces less motor block than racemic bupivacaine. The potential benefits of levobupivacaine with regard to motor blockade require further investigations. In this study, we compared the efficacy, dose requirements, side effects, and motor block observed with epidural levobupivacaine and ropivacaine when given in combination with small-dose morphine for 60 h after major abdominal surgery. Postoperatively, 50 patients were randomly allocated, in a double-blinded manner, to patient-controlled epidural analgesia with the same settings and without basal infusion, using 0.1% levobupivacaine or 0.1% ropivacaine. Both were combined with an epidural infusion of 0.1 mg/h morphine. Pain scores, side effects, motor block, and local anesthetic consumption were measured for 60 h. Pain scores measured on a 100-mm visual analog scale were approximately 20 mm at rest and 40 mm during mobilization in both groups. Bromage scores were 1 for all patients after the fourth postoperative hour. Consumption of levobupivacaine and ropivacaine were similar: 344 +/- 178 mg levobupivacaine versus 347 +/- 199 mg ropivacaine 48 h postoperatively. On postoperative day 2, 19 patients in the ropivacaine group versus 12 in the levobupivacaine group were able to ambulate (P < 0.05). No difference was noted concerning incidence of side effects. We conclude that when used as patient-controlled epidural analgesia and combined with small-dose epidural morphine, 0.1% levobupivacaine and 0.1% ropivacaine produce comparable postoperative analgesia with a similar incidence of side effects.

IMPLICATIONS

Small concentrations (0.1%) of epidural levobupivacaine and ropivacaine combined with morphine (0.1 mg/h) produce comparable analgesia and have similar side effects for similar dose requirements.

[New anesthetic and resuscitation techniques in adult cardiac surgery]

Anesthetic techniques and treatment of cardiac surgery patients have considerably evolved over the past twenty years. The demand for cardiac surgical procedures is increasing. This demand coincides with a change in the profile of patients presenting for surgery, requiring modification in perioperative management strategies. Several new anesthetics, related drugs, and technologies have become available in recent years that inevitably have made new approaches with patient management possible. In parallel to these new developments, there have appeared real opportunities to apply novel physiologic and pharmacologic concepts that may redefine our clinical practice. Fast-tracking, which emphasizes the major role of anesthetic management in postoperative outcome, is one such line of investigation. Fast-tracking was first introduced in an attempt to decrease the time to tracheal extubation and reduce expensive time in intensive care unit areas. Large doses of opioids have been clearly identified as a factor in delaying weaning from mechanical ventilatory support after cardiac surgery. Thus, early investigations emphasized the importance of limiting the dose of potent opioid analgesics during the intraoperative period to achieve early recovery. Supplementation with hypnotic drugs allows reduction of the opioid dose, enabling earlier extubation without compromising hemodynamic stability. Fast track cardiac anesthesia (FTCA) is becoming an accepted practice for perioperative management of cardiac surgical patients. FTCA is a key component to successful conduction of fast-track cardiac surgery. Also, analgesia management in cardiac surgery is becoming more important with the establishment of minimally invasive direct coronary artery bypass surgery and fast track management of conventional cardiac surgery patients.

Peripheral vascular surgery: update on the perioperative non-surgical management for high cardiac risk patients

This review of the recent literature regarding perioperative management in peripheral vascular surgery emphasizes some of the important features for the 2003 state-of-the-art on non surgical perioperative care for these high cardiac risk patients. The most adapted preoperative cardiac evaluation for each patient is guided by its individual risk factors and clinical history. Perioperative medication should nowadays consist of pre- and postoperative beta-blockers and acetyl salicylic acid, both reducing cardiac morbidity and mortality. Neuraxial locoregional anaesthesia techniques are reasonable alternatives to general anaesthesia because of their potential advantages, by reducing postoperative inflammatory response and reducing procoagulating activity, and increasing peripheral vascular graft patency, but the individual benefit/risk balance has always to be evaluated for patients submitted to aggressive antithrombotic therapy. During the postoperative course, early detection and treatment of postoperative myocardial ischemia or infarction by ST wave changes and/or cardiac enzyme control has to be considered.

[Use of ropivacaine for peridural postoperative analgesia]

OBJECTIVES

To describe pharmacology and toxicology of ropivacaine. To assess the clinical efficacy of ropivacaine when used for postoperative epidural analgesia and to provide recommendations for clinical practice.

DATA SOURCES

Search in the Medline data base of original articles in French and English published since 1995, using the following key words: ropivacaine, postoperative analgesia, epidural, caudal block.

STUDY SELECTION

Prospective randomised studies in adults and children were selected. Letters to editors and editorials were excluded.

DATA EXTRACTION

Articles have been analyzed: to determine the dose of ropivacaine required for postoperative epidural analgesia, to assess the benefits of combination of epidural ropivacaine and additives (opioids or other), to compare epidural ropivacaine and bupivacaine and to assess the use of ropivacaine via caudal route for paediatric postoperative analgesia.

DATA SYNTHESIS

20 mg h-1 of ropivacaine is required to provide effective analgesia. This dose produces a motor block in a significant number of patients. Combination with an opioid allows for a reduction in ropivacaine requirement and subsequently in the incidence of motor blockade. In adults, equipotency ratio of ropivacaine and bupivacaine varies between 1.5/1 and 1/1 depending upon the concentration used. At equipotent doses, early postoperative mobilisation is facilitated with ropivacaine. In case of paediatric caudal analgesia, this ratio is close to 1.

CONCLUSIONS

Epidural ropivacaine combined with opioid provide good postoperative pain relief. Reduction in the incidence of motor blockade and safe toxicological profile make this local anaesthetic a suitable alternative of bupivacaine for postoperative epidural analgesia.

A comparison of 0.1% and 0.2% ropivacaine and bupivacaine combined with morphine for postoperative patient-controlled epidural analgesia after major abdominal surgery

Ropivacaine (ROPI), which is less toxic and produces less motor block than bupivacaine (BUPI), seems attractive for epidural analgesia. Few data are available concerning dose requirements of epidural ROPI when combined with morphine. In this study, we compared the dose requirements and side effects of ROPI and BUPI combined with small-dose morphine after major abdominal surgery. Postoperatively, 60 patients were randomly allocated (double-blinded manner) to four groups: patient-controlled epidural analgesia with the same settings using 0.1% or 0.2% solution of ROPI or BUPI combined with an epidural infusion of 0.1 mg/h of morphine. Pain scores, side effects, motor block, and local anesthetic consumption were measured for 60 h. Pain scores and the incidence of side effects did not differ among the groups. Consumption of ROPI and BUPI were similar in both 0.1% groups. Doubling the concentration significantly reduced the consumption (milliliters) of BUPI (P < 0.05) but not of ROPI. Consequently, using ROPI 0.2% significantly increased the dose administered as compared with ROPI 0.1% (ROPI 0.1% = 314 +/- 151 mg and ROPI 0.2% = 573 +/- 304 mg at Hour 48; P < 0.05). Patient-controlled epidural analgesia with the 0.1% or 0.2% solution of ROPI or BUPI combined with epidural morphine resulted in comparable analgesia. As compared with ROPI 0.1%, the use of ROPI 0.2% increased consumption of local anesthetic without improving analgesia.

IMPLICATIONS

Small-dose (0.1%) ropivacaine and bupivacaine have similar potency and result in comparable analgesia and incidence of side effects.

Hemodynamic effects of epinephrine associated to an epidural clonidine-bupivacaïne mixture during combined lumbar epidural and general anesthesia

Clonidine or epinephrine are frequently combined to epidural local anesthetics to strengthen sensory block and prolong analgesia. Both drugs impair the hemodynamic profile of central neural blockade but the effects of their combination on arterial pressure and heart rate are not known and were examined in this double-blind prospective randomised study. Forty four patients scheduled for lumbar disc surgery were allocated to two groups. Epidural anesthesia was obtained by administration of 150 micrograms clonidine in 15 ml bupivacaine 0.25% solution without (group C) or with (group C + E) 37.5 micrograms epinephrine. Systolic, mean, diastolic arterial pressure and heart rate were measured throughout the study. Combined epidural and general anesthesia induced a significant decrease in arterial pressure and heart rate in both groups. SAP and MAP decreased significantly less in the patients receiving epinephrine. Low dose epidural epinephrine decreases arterial pressure instability during combined epidural and general anesthesia.