Biomedical subjects

Raimondo Ascione

Publications and source records attributed to Raimondo Ascione.

At least 19 recordsLinked to original sources

PubMed2006

Morbidity and mortality following acute conversion from off-pump to on-pump coronary surgery.

OBJECTIVE: Many studies have described reduced morbidity in hospital and equivalent midterm outcomes with off-pump coronary artery bypass (OPCAB) surgery compared to conventional CABG (CABG-CPB). However, OPCAB is sometimes converted acutely to CABG-CPB. We describe the risk of acute conversion and compare patients' outcomes for acutely converted OPCAB with unconverted OPCAB and CABG-CPB. METHODS: Consecutive acute conversions, i.e. OPCAB patients in whom CPB was instituted urgently for hemodynamic or electrical instability, cardiac arrest or uncontrolled bleeding, were compared with propensity-matched unconverted OPCAB and CABG-CPB patients. Relative risks of death and complications in hospital, and subsequent survival were estimated. RESULTS: The risk of acute conversion between 1996 and 2004 was 1.1% (27/2492): 5.1% in the first 2 years, 2.2% in the third year and 0.8% subsequently. Odds ratios for death in hospital compared to unconverted OPCAB and CABG-CPB were 4.4 (95% confidence interval (CI) 0.67-29.1) and 4.7 (95% CI 1.03-21.1), respectively, and ranged from 0 to 4.5 for serious complications. Converted patients had an increased hazard of death for 3 years after surgery compared to unconverted OPCAB (hazard ratio 3.21, 95% CI 1.20-8.59) and CABG-CPB patients (hazard ratio 3.23, 95% CI 1.41-7.39). CONCLUSIONS: Experienced OPCAB surgeons have a low risk of acute conversion. Acutely converted patients have a moderately increased risk of death and serious complications in hospital. These risks are difficult to quantify precisely because conversion is rare.

Aged↗

PubMed2006

Novel repair for late posttraumatic aortic valve injury and root pseudoaneurysm.

We report a case of posttraumatic aortic valve regurgitation and pseudoaneurysm of the aortic root diagnosed 22 months after a road traffic accident. The surgical treatment consisted of exclusion of the pseudoaneurysm with direct closure of the entry tear in the right coronary sinus followed by insertion of a Toronto stentless prosthesis (St. Jude Medical, St. Paul, MN). This surgical approach aimed to cover the repaired entry tear ensuring exclusion of the site. Recovery was uneventful and 12 month follow-up was unremarkable.

Accidents, Traffic↗

PubMed2006

Splanchnic organ injury during coronary surgery with or without cardiopulmonary bypass: a randomized, controlled trial.

BACKGROUND: We investigated the efficacy of coronary surgery with or without cardiopulmonary bypass in protecting the function of the small intestine, liver, and pancreas. METHODS: Patients were randomized to off-pump coronary artery bypass grafting (OPCAB) or coronary artery bypass grafting with cardiopulmonary bypass (CABG-CPB). Small intestine function was assessed by differential four sugars (O = methyl-D-glucose, D-xylose, L-rhamnose, and lactulose) permeability and absorption tests. Liver function was assessed by monoethylglycinexylidide/lidocaine ratios and by serial measurements of transaminases (aspartate transaminase and alanine-amino transferase), bilirubin, and alkaline phosphatase. Pancreatic function was assessed by serial measurements of insulin/glucagon ratio, amylase, and glucose. Forty patients were recruited (20 per group). RESULTS: Permeability and absorption were more impaired in the OPCAB group immediately after surgery, but returned to baseline levels in both groups by postoperative day 5 (interaction of surgery type and time; p = 0.05 and p = 0.02, respectively). Monoethylglycinexylidide/lidocaine ratios were not different in the two groups. Aspartate transaminase and alanine-amino transferase levels were higher in the CABG-CPB group for the first postoperative day, but levels converged by day 3 (interaction of surgery type and time; p < 0.0001 and p = 0.04, respectively). The bilirubin level for the OPCAB group overshot the CABG-CPB group at 36 hours before returning to a similar level 60 hours postoperatively. Amylase levels were higher in the CABG-CPB group than in the OPCAB group (1.17 times; p = 0.03); other markers of pancreatic function showed no differences between the groups. CONCLUSIONS: Early small intestine function is worse with OPCAB; all functions recover to similar levels in both groups by day 5. Conversely, pancreatic function is worse with the CABG-CPB group than with the OPCAB group. Hepatic metabolic function does not differ by type of surgery to the end of the operation. Postoperative hepatocellular injury was worse with the CABG-CPB group.

Aged↗

PubMed2006

Coronary surgery in patients with preexisting chronic atrial fibrillation: early and midterm clinical outcome.

BACKGROUND: The purpose of this study was to investigate the effect of preexisting atrial fibrillation on early and midterm clinical outcome in patients undergoing coronary surgery. METHODS: All elective patients undergoing coronary artery bypass grafting surgery between April 1996 and September 2002 were investigated. Patients were grouped according to their preoperative cardiac rhythm: sinus rhythm (SR) or preexisting atrial fibrillation (AF). In-hospital clinical outcomes and 5-year patient survival and cardiac-related event-free survival were compared using regression methods to adjust for differences between the groups. In all, 5,092 patients were identified, 175 (3.4%) with a history of preexisting AF. These patients were older (median, 64 versus 68 years) and had higher Parsonnet scores (median, 4 versus 8) than the SR group. Previous myocardial infarction, cerebrovascular accident, hypertension, diabetes mellitus, renal impairment, peripheral vascular disease, ejection fraction less than 50%, previous surgery, congestive heart failure, and use of angiotensin-converting enzyme inhibitors were also more common in the AF group. RESULTS: There were 60 in-hospital deaths (1.2%), with no difference between the two groups (odds ratio 1.02, 95% CI: 0.35 to 2.94). Atrial fibrillation patients were more likely to need intraoperative inotropes (p = 0.044), postoperative intra-aortic balloon pump (p = 0.038), and were less likely to be discharged within 6 days (p = 0.017). The risk of death in the 5 years after surgery was higher in the AF group (relative risk 1.49, 95% CI: 1.06 to 2.08, p = 0.020). In the AF group, 109 (62.2%) patients were cardioverted spontaneously by surgery, but only 69 (39.4%) remained in SR until discharge. Longer-term rhythm follow-up data were available for 48 of these 69 patients, and only 36 remained in SR at a median follow-up of 1,483 days (interquartile range, 1,120 to 2,209). Spontaneous conversion to SR after surgery did not confer a midterm survival benefit (p = 0.91). CONCLUSIONS: Preexisting AF in patients undergoing coronary artery bypass graft surgery is not associated with increased in-hospital mortality and major morbidity; however, it is a risk factor for reduced 5-year survival. Spontaneous cardioversion to SR during surgery is transient in the majority of patients and is not associated with midterm survival benefit.

Aged↗

PubMed2006

The effect of diabetes mellitus on patients undergoing coronary surgery: a risk-adjusted analysis.

BACKGROUND: Surgical case-mix is seriously worsening, and the results of surgical revascularization on high-risk cohorts should be continuously evaluated. This study investigates the influence of diabetes mellitus on the short and midterm outcome in the modern era of coronary surgery. METHODS AND RESULTS: Patients who underwent first-time coronary artery bypass grafting from April 1996 to October 2003 were classified into diabetic and nondiabetic groups. Data were prospectively collected and retrospectively analyzed. A total of 5259 patients were studied, and of these 877 (17%) were diabetic. Patients with diabetes were more likely to be female, have a higher body mass index, be in an advanced New York Heart Association class and Canadian Cardiovascular Society class, have a history of congestive heart failure, have a poor ejection fraction, renal failure, and more extensive coronary artery disease than the nondiabetic group (P < .001 for all). In-hospital mortality was 2.2% and 1% for diabetic and nondiabetic patients, respectively; however, diabetes was not found to be an independent risk factor for in-hospital mortality (odds ratio = 1.63; 95% confidence interval 0.92-2.88; P = .089). Postoperative complications were comparable in the two groups, with only renal, neurologic, and gastrointestinal complications significantly associated with diabetes (all P < or = .05). There was no association between diabetes mellitus and postoperative infective complications. Diabetes remained an independent predictor of 5-year mortality (hazard ratio 1.55; 95% confidence interval 1.22-1.96; P < .001) and of lower 5-year cardiac-related event-free survival. CONCLUSION: Despite a worsening cohort, diabetic patients could be surgically revascularized with low morbidity and mortality, comparable with control patients. The negative effect of diabetes mellitus on the longer-term mortality and morbidity remains a problem.

Aged↗

PubMed2006

Value of wedge resection for lung cancer in poor cardiopulmonary status patients.

The strategic management of primary lung cancer in patients with poor cardiopulmonary status is still controversial. The aim of this study was to ascertain the early and late results of wide-margin wedge resection with curative intent in this group of patients. Between January 1995 and January 2002, 24 patients (13 males; mean age, 69.96 years) with baseline poor cardiopulmonary status underwent wide-margin wedge resection of preoperatively diagnosed primary lung cancer. All patients suffered from chronic obstructive pulmonary disease and 9 (37.5%) also had symptomatic ischemic heart disease. Eight patients were in New York Heart Association class III and 12 were in class IV. There were no post-operative deaths. Complications included chest infection in 3, surgical emphysema with prolonged air leak in 1, and atrial fibrillation in 6. Overall 7-year survival was 23.3%. Three patients with ischemic heart disease suffered late non-cancer-related death due to myocardial infarction at 48, 60, and 60 months postoperatively. Cancer-free 5-year survival was 54.3%, with 7/24 (29%) late recurrences. Our study suggests that wide-margin wedge resection is a valuable surgical option for primary lung cancer in patients with poor cardiopulmonary status.

Aged↗

PubMed2005

Retinal and cerebral microembolization during coronary artery bypass surgery: a randomized, controlled trial.

BACKGROUND: We sought to compare the effects on ophthalmic function of coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) and off-pump (OPCAB) grafting and to investigate whether retinal microvascular damage is associated with markers of cerebral injury. METHODS AND RESULTS: Retinal microvascular damage was assessed by fluorescein angiography and color fundus photography. Ophthalmic function was tested by the logarithm of the minimum angle of resolution visual acuity (VA), and cerebral injury, by transcranial Doppler ultrasound-detected emboli and S100 protein values. Twenty patients were randomized. Fluorescein angiography and postoperative VA could not be obtained for 1 CABG-CPB patient. Retinal microvascular damage was detected in 5 of 9 CABG-CPB but in none of 10 OPCAB patients (risk difference, 55%; 95% confidence interval [CI], 23% to 88%; P=0.01). Color fundus photography detected microvascular damage in 1 CABG-CPB patient but in no OPCAB patients; this lesion was associated with a field defect, which remained after 3 months of follow-up. There was no difference in postoperative VA. Doppler high-intensity transient signals (HITS) were 20.3 times more frequent in the CABG-CPB than in the OPCAB group (95% CI, 9.1 to 45; P<0.0001). Protein S100 levels were higher in the CABG-CPB than in the OPCAB group 1 hour after surgery (P<0.001). HITS were 14.7 times more frequent (95% CI, 3.5 to 62; P=0.001) and S100 level 2.1 times higher (95% CI, 1.3 to 3.5; P=0.005) when retinal microvascular damage was present. CONCLUSIONS: The relative frequency of retinal microvascular damage between groups shows the extent to which the risk of cerebral injury is reduced with OPCAB. Imaging of part of the cerebral circulation provides evidence to validate markers of cerebral injury.

Aged↗

PubMed2005

In-hospital patients exposed to clopidogrel before coronary artery bypass graft surgery: a word of caution.

BACKGROUND: The aim of our study was to investigate the independent effect of preoperative exposure to aspirin, heparin, and clopidogrel on early clinical outcomes of in-hospital referral patients undergoing first time coronary artery bypass graft (CABG) surgery. METHODS: Outcomes for in-hospital referrals for CABG between January 2001 and January 2002 were prospectively recorded. Exposure to aspirin, heparin, and clopidogrel during the 5 days before surgery was recorded, and their effect on outcome was explored using multiple regression methods. The effect of clopidogrel given within 48 hours before surgery versus stopped at least 48 hours before the operation was also investigated. RESULTS: In-hospital referral patients represented 40% (473 of 1,185) of the total surgical population; 304 (64.7%) were prescribed aspirin, 116 (24.7%) heparin, 91 (19.4%) clopidogrel, and 133 (28.3%) had all anticoagulants stopped 5 days before surgery. In-hospital mortality was 2.3% (95% confidence interval [CI]: 1.1 to 4.1) and was highest among those exposed to clopidogrel (odds ratio 16.9, 95% CI: 2.10 to 136, p = 0.008). Seven of the 11 deaths occurred in patients given clopidogrel. Postoperative intraaortic balloon pump, arrhythmia, reintubation, and stroke were all significantly more common when clopidogrel was prescribed (relative risk estimates all greater than 1.5, p values all < or = 0.021). Blood loss was 37% higher in the patients given clopidogrel (95% CI: +3% to +82%, p = 0.033). Clopidogrel patients were more likely to need a reoperation for bleeding (p < 0.001) and require transfusions (p < or = 0.015). Intubation time and hospital stay were also longer (p = 0.021 and p = 0.019, respectively). Heparin was also associated with longer hospital stay (p < 0.001) and aspirin use with reduced stay (p = 0.041), but for all other outcomes, no association with aspirin or heparin use was found. Comparison of subgroups of clopidogrel patients suggested mortality was highest when clopidogrel was given in the 48 hours before surgery. CONCLUSIONS: Our study suggests that among in-hospital referral patients, preoperative exposure to clopidogrel within 5 days before CABG may increase early mortality and morbidity, and that the mortality risk is greatest when the drug is given within 48 hours of surgery.

Aged↗

PubMed2005

Eight years survival after partial left ventriculectomy.

Remodelling the left ventricle by partial left ventriculectomy (PLV) has been proposed as an alternative surgical treatment for end-stage heart failure. We present the case of a patient with dilated idiopathic cardiomyopathy who underwent PLV and remains in NYHA functional Class I eight years after the surgery.

Aged↗

PubMed2005

Severe tracheal compression as a late complication of plombage.

Prior to the antituberculous drugs era, plombage was commonly performed for the management of pulmonary tuberculosis. However, this procedure has been associated with a variety of early and late complications depending on the technique as well as the material used. We report a rare case of severe tracheal compression as a late complication of plombage and a review of the literature.

Aged↗

PubMed2005

Aortic coarctation repair with patch graft aortoplasty and severe hemoptysis.

This report describes the successful treatment of a confirmed case of hemoptysis from a false aneurysm at the site of a previous coarctation repair. Professionals involved in the clinical care of patients that have undergone previous coarctation repair with patch graft aortoplasty, should be aware of the late risk of false aneurysm occurrence. Periodically screening patients with magnetic resonance imaging to prevent potentially fatal complications is recommended.

Adult↗

PubMed2004

Predictors of new malignant ventricular arrhythmias after coronary surgery: a case-control study.

OBJECTIVES: We sought to investigate the relationship between perioperative factors and the occurrence of ventricular tachycardia (VT) and ventricular fibrillation (VF), as well as the impact of VT/VF on early and late mortality. BACKGROUND: Both VT and VF are rare but serious complications after coronary artery bypass graft surgery (CABG), and their etiology and implications remain uncertain. METHODS: Data on 4,411 consecutive patients undergoing CABG (1,154 [25.8%] had off-pump surgery) between April 1996 and September 2001 were extracted from a prospective database and analyzed. Odds ratios (ORs) describing associations between possible risk factors and VT/VF were estimated separately. Factors observed to be significantly associated with VT/VF were further investigated using multivariate logistic regression. RESULTS: Sixty-nine patients suffered VT/VF (1.6%). There were 61 (1.4%) in-hospital/30-day deaths, 15 among patients who had postoperative VT/VF (21.7%). Patient factors independently associated with an increase in the odds of VT/VF included age <65 years, female gender, body mass index <25 kg/m(2), unstable angina, moderate or poor ejection fraction, and the need for inotropes and an intra-aortic balloon pump (OR 1.72 to 4.47, p < 0.05). After adjustment, off-pump surgery was associated with a substantial but nonsignificant protective effect against VT/VF (OR 0.53, 95% confidence interval [CI] 0.25 to 1.13; p = 0.10). Actuarial survival at two years was 98.2% among patients who had VT/VF and who survived to discharge/30 days, compared with 97.0% for the control group (adjusted hazard ratio 0.96 (95% CI 0.40 to 2.31, p = 0.92). CONCLUSIONS: The incidence of VT/VF is low in patients undergoing coronary surgery but is associated with high in-hospital mortality. The late survival of the discharged VT/VF patients compares favorably with that of controls.

Adolescent↗

PubMed2004

Trainees operating on high-risk patients without cardiopulmonary bypass: a high-risk strategy?

BACKGROUND: The safety of teaching off-pump coronary artery bypass grafting to trainees is best tested in high-risk patients, who are more likely to experience significant morbidity after surgery. This study compared outcomes of off-pump coronary artery bypass grafting operations performed by consultants and trainees in high-risk patients. METHODS: Data for consecutive patients undergoing off-pump coronary artery bypass grafting were collected prospectively. Patients satisfying at least one of the following criteria were classified as high-risk: age older than 75 years, ejection fraction less than 0.30, myocardial infarction in the previous month, current congestive heart failure, previous cerebrovascular accident, creatinine greater than 150 micromol/L, respiratory impairment, peripheral vascular disease, previous cardiac surgery, and left main stem stenosis greater than 50%. Early morbidity, 30-day mortality, and late survival were compared. RESULTS: From April 1996 to December 2002, 686 high-risk patients underwent off-pump coronary artery bypass grafting revascularization. Operations by five consultants (416; 61%) and four trainees (239; 35%) were the focus of subsequent analyses. Nine visiting or research fellows performed the other 31 operations. Prognostic factors were more favorable in trainee-led operations. On average, consultants and trainees grafted the same number of vessels. There were 18 (4.3%) and 5 (1.9%) deaths within 30 days, and 14 (3.4%) and 5 (1.9%) myocardial infarctions in consultant and trainee groups, respectively. After adjusting for imbalances in prognostic factors, odd ratios for almost all adverse outcomes implied no increased risk with trainee operators, although patients operated on by trainees had longer postoperative stays and were more likely to have a red blood cell transfusion. Kaplan-Meier cumulative mortality estimates at 24-month follow-up were 10.5% (95% confidence interval, 7.7% to 14.2%) and 6.4% (95% confidence interval, 3.8% to 10.9%) in consultant and trainee groups, respectively (hazard ratio = 0.60 [95% confidence interval, 0.37 to 0.99]; p = 0.05). CONCLUSIONS: Off-pump coronary artery bypass grafting surgery in high-risk patients can be safely performed by trainees.

Aged↗

PubMed2004

Beating heart against cardioplegic arrest studies (BHACAS 1 and 2): quality of life at mid-term follow-up in two randomised controlled trials.

AIMS: Off-pump coronary bypass grafting (OPCAB) has short-term benefits compared to conventional bypass grafting using the heart-lung machine (CABG-CPB) but may compromise longer term outcome. We aimed to compare generic and disease specific quality of life (QoL) two to four years after surgery in participants in two randomised controlled trials of OPCAB vs. CABG-CPB. METHODS AND RESULTS: Trial participants were sent four questionnaires (SF-36, EuroQol/EQ5D, Seattle Angina Questionnaire (SAQ) and Coronary Revascularisation Outcome Questionnaire (CROQ)) to assess generic and disease-specific quality of life (QoL). Of 401 participants, 22 (5.5%) had died; of the 379 survivors, 328 responded (86.5%; 159 CABG-CPB and 169 OPCAB). Median duration of follow-up was three years. QoL scores for both groups were very similar and differences between groups were not significant (p>0.05 for all questionnaires and dimensions). Summary SF-36 scores showed poorer than normal physical QoL but normal mental QoL. Among all responders, there was a tendency for CROQ scores (core total, physical and psychosocial functioning and satisfaction with treatment) to deteriorate with time after the operation (p< or =0.05). CONCLUSION: Two to four years after surgery, patients randomised to OPCAB and CABG-CPB had similar symptoms, generic and disease-specific QoL.

Angina Pectoris↗

PubMed2004

Coronary artery bypass grafting on the beating heart: surgical revascularization for the next decade?

This review considers whether coronary artery bypass grafting (CABG) performed on the beating heart (off-pump or OPCAB) will supersede conventional CABG utilizing cardiopulmonary bypass (CPB) and cardioplegic arrest as the accepted gold standard. Randomized controlled trials, case-matched reports and observational studies have demonstrated lower morbidity in off-pump compared to conventional on-pump CABG with equivalent mid-term outcome at a significantly lower cost. Patients referred for surgical revascularization are increasingly elderly with more co-morbid medical conditions and elimination of CPB-related morbidity in these groups is associated with the most pronounced improvements in outcome, at least in observational studies. Long-term outcome, and in particular, long-term graft patency following OPCAB has not yet been reported. A barrier to the more widespread acceptance of OPCAB is the poor provision for training in off-pump techniques although structured cardiothoracic training that includes OPCAB surgery has been shown to be both possible and safe for patients. The evidence available to date therefore strongly supports the assertion that OPCAB may become the new gold standard in surgical revascularization. Whether it will ultimately replace conventional CABG, however, is dependent on the results of long-term patency studies and the wider development of adequate training programmes.

Cardiomyopathies↗

PubMed2004

Value of wide-margin wedge resection for solitary pulmonary nodule: a single center experience.

OBJECTIVE: Despite refinements of the diagnostic procedures, often surgery remains the only option to ascertain the histopathological nature of solitary pulmonary nodules (SPN). Aim of the present study was to ascertain the value of wide-margin wedge resection (WMWR) with curative intent in a consecutive cohort of patients afflicted by SPN. METHODS: From January 1995 to January 2002, 129 patients (74 male, mean age 60.5+/-14.4 years) underwent WMWR of a SPN. In-hospital outcome was prospectively collected and retrospectively analyzed. Incidence of malignancy was obtained by histology. Patients found to be afflicted by primary lung cancer (PLC) were sub-grouped according to their preoperative cardiopulmonary status (CPS). In-hospital and mid-term clinical outcome of all the patients is presented. RESULTS: There were 3 (2.3%) in-hospital deaths. Distribution of histology included 61 (47.3%) PLC (41 poor CPS), 20 (15.5%) secondary lung cancer (SLC), and 48 (37.2%) miscellaneous benign lesions. Twenty patients with PLC were fit and underwent completion lobectomy within 2 weeks following WMWR. Hospital length of stay was longer in patients with PLC as compared to patients with SLC (P=0.04). There were 17/61 (27%) recurrences in the PLC group. Of these, 2 occurred in fit patients undergone previous WMWR-lobectomy, and 15 in patients with poor baseline CPS. All these patients were referred for adjuvant therapy. Overall 5-year survival of the PLC group was 66% (61.1% for those with poor CPS and 82.5% for those with good CPR (P=NS). Seven out of 20 (35%) patients with SLC had late recurrent disease, leading to 1 re-operation. The overall 5-year survival in this group was 58.8%. There was only 1 non-related late death in the benign group. CONCLUSIONS: The WMWR resection of a primarily malignant SPN determines a valuable 5-year survival but a relatively high incidence of late recurrence. WMWR is a safe and effective surgical option for patients presenting with poor cardiopulmonary reserve.

Aged↗

PubMed2004

Effect of cardiopulmonary bypass on cortical cerebral oxygenation during coronary artery bypass grafting.

OBJECTIVE: To investigate the changes in cerebral oxygenation during coronary artery bypass grafting (CABG) with normothermic cardiopulmonary bypass (CPB) using near infrared spectroscopy. METHODS: Measurement of cerebral cortical oxygenation changes included concentration of deoxygenated haemoglobin [HHb], oxygenated haemoglobin [O(2)Hb], changes in the redox status of the cytochrome c oxidase [Cyt-Ox], cerebral saturation as expressed by the tissue oxygenation index (TOI), and cerebral blood volume (CBV) as expressed by tissue haemoglobin index (THI). Measurements were performed in 19 consecutive patients undergoing normothermic (34-36 degrees C) CPB. Data were recorded at 0.5s intervals and averaged into 30 s epochs. Data analysis was carried at baseline, 1, 20, and 40 min after start of CPB, at rewarming, on weaning from CPB, and at closing of chest. RESULTS: There were no in-hospital death, neurological deficits, or myocardial infarcts. Compared to baseline, during the entire CPB duration, there was a marked reduction in [O(2)Hb] and CBV which reached their worst level 40 min after initiation of CPB (from -3.03+/-5.1 to -9.25+/-7.20 micromol/l for [O(2)Hb], and a 24% reduction for CBV (both P<0.0001). The deterioration in [O(2)Hb] was recovered by the end of surgery, while the changes in CBV persisted. No significant changes occurred with respect to [HHb], [Cyt-Ox], and TOI. CONCLUSIONS: Conventional CABG is responsible for deterioration in [O(2)Hb], and CBV, which peak at 40-60 min following initiation of CPB. The changes in [O(2)Hb] are reversible whereas the reduction of CBV persists to the end of the surgery. This suggests a transient impairment in the autoregulatory mechanisms controlling cerebral blood flow following discontinuation of cardiopulmonary bypass.

Aged↗

PubMed2004

Monitoring the performance of residents during training in off-pump coronary surgery.

OBJECTIVE: Control charts (eg, cumulative sum charts) plot changes in performance with time and can alert a surgeon to suboptimal performance. They were used to compare performance of off-pump coronary artery bypass surgery between a consultant and four resident surgeons and to compare performance of off-pump coronary artery bypass surgery and conventional coronary artery bypass grafting within surgeons. METHODS: Data were analyzed for consecutive patients undergoing coronary artery bypass grafting who were operated on by one consultant or one of four residents. Conversions were analyzed by intention to treat. Perioperative death or one or more of 10 adverse events constituted failure. Predicted risks of failure for individual patients were derived from the study population. Variable life-adjusted displays and risk-adjusted sequential probability ratio test charts were plotted. RESULTS: Data for 1372 patients were analyzed; 769 of the procedures were off-pump coronary artery bypass operations (56.0%). The consultant operated on 382 patients (293 off-pump, 76.7%), and the residents operated on 990 (474 off-pump, 47.9%). Patients operated on by residents tended to be older, more obese, more likely to require an urgent operation, and more likely to need a circumflex artery graft but less likely to have triple-vessel disease. There were 7 conversions (consultant 5, residents 2). The overall failure rate was 8.5% (9.2% for consultant's operations and 8.2% for residents' operations), including 10 deaths (0.7%). Predicted and observed risks of failure were similar for all five surgeons. After 100 off-pump coronary artery bypass operations, performance was the same or better for the residents as for the consultant. For all surgeons, performance was the same or better for off-pump as for conventional coronary artery bypass grafting. CONCLUSIONS: Off-pump coronary artery bypass surgery can be safely taught to cardiothoracic residents. Implementation of continuous performance monitoring for residents is practicable.

Cardiology↗