Anticoagulant therapy with vitamin K antagonists is effective in the prevention and treatment of thrombotic disease. The variable effect of these agents and the relatively small therapeutic width necessitate frequent checks on the intensity of the anticoagulation therapy as well as frequent dose-adjustments. Recently, small and reliable portable machines have become available which enable patients themselves, by means of a drop of blood obtained from a finger prick, to measure the intensity of the anticoagulation therapy and if necessary to adjust the treatment dose. In studies within the Netherlands where (selected) patients determined the 'international normalised ratio' (INR) themselves and if necessary adjusted the dose of the anticoagulant medication, the INR was mostly within the therapeutic target area. Furthermore, the independence, the possibility for travelling and the time saved were experienced as positive aspects. Under certain conditions, allowing patients themselves to check the INR and if needs be to adjust the dose of the anticoagulation treatment, may be an acceptable alternative for anticoagulation therapy check-ups performed by the thrombosis service.
To determine the clinical impact of endoscopic vein-graft harvesting in patients undergoing coronary artery bypass grafting (CABG) who are at risk for surgical site infection.Retrospective cohort study.Of patients undergoing elective CABG between March 1st 2006 and March 1st 2007, 335 were eligible for analysis. The results of endoscopic vein-graft harvesting were compared with traditional open vein-graft harvesting. Medical records of all patients were reviewed and data collection was completed by means of a telephone survey. The primary outcome measure was the incidence of surgical site infections. Secondary outcome measures were duration of hospital stay, patient satisfaction and quality of life.Among the 335 patients included the incidence of surgical site infection was 2.5% following open harvesting (n = 236) and 2.0% following endoscopic harvesting (n = 99; p = 0.08). Patients in the endoscopic harvesting group had more risk factors for surgical site infection (diabetes, peripheral artery disease, obesity). Surgical site infection after open harvesting resulted in a prolonged hospital stay and a higher number of patients undergoing open wound treatment, re-admittance and additional surgical procedures. Total mean hospital stay in the open harvesting group was 7.9 days and 6.1 days in the endoscopic harvesting group (p < 0.05). Patients were more satisfied with the surgical wound after endoscopic harvesting compared with open harvesting (patient satisfaction score: 8.6 versus 7.8; p < 0.001).Endoscopic vein-graft harvesting resulted in a - statistically non-significant - lower incidence of surgical site infection than open harvesting, although the patients had a higher risk for infections. Infections in the endoscopic harvesting group were less severe. The hospital stay was shorter and the patient satisfaction was higher than in the open harvesting group.
Recently the media, including this journal, paid attention to some cases of true or alleged failure of open heart surgery, i.e. mortality due to heart valve replacement, poor outcome in paediatric heart surgery (the so-called Bristol affair), and a series of failed Björk-Shiley mechanical heart valves, thereby questioning the safety of heart surgery. Viewed from a safety perspective, there is a need for criteria for safety assessment of health care services, initiatives aiming at staff exchange and transparency of performance data, and the role of safety committees and safety management plans. Medicolegal developments illustrate the increasing relevance of risk information for patients based on physician experience and hospital performance with respect to maintaining safety standards.
Atrial fibrillation (AF) is the most common arrhythmia in humans. The majority of patients with AF can function reasonably well on a daily basis with anti-arrhythmic drugs. A small proportion of patients with AF remain symptomatic despite anti-arrhythmic drugs. They might have an indication for invasive treatment for AF, such as endovascular catheter ablation (effective particularly in paroxysmal AF) or the Cox-Maze procedure (open heart surgery), in which the conductivity between the pulmonary veins and the left atrium is blocked. Hybrid thoracoscopic pulmonary vein isolation (VATS-PVI) is a new minimally invasive treatment for AF where the cardiothoracic surgeon and cardiologist work closely together. During this procedure the cardiologist performs electrophysiological measurements to verify whether the blockade of conductivity is successful. This approach has a success rate of 86% at a follow-up of 12 months.
In patients with symptoms of ischaemic heart disease, despite optimal medical therapy, a PCI or CABG may be indicated if the coronary arteries are narrowed. Decisions regarding PCI or CABG need to be taken by the local heart team, consisting of a cardiothoracic surgeon and an interventional cardiologist. After a complete diagnostic work-up, the referring cardiologist presents the patient with accompanying written information supporting revascularisation. The decision of the heart team takes the characteristics of each individual patient into account and, most importantly, the coronary angiogram. Despite improvements in medical and interventional treatments, mortality and morbidity remain high among patients with NSTEMI. Early risk stratification is essential to determine those patients who can be treated safely with medical therapy and those who require interventional treatment. Ad hoc PCI is indicated in patients with STEMI or haemodynamic instability.
Mechanical circulatory support has become an increasingly important therapeutic option in the field of cardiology, both with regard to treatment of patients in cardiogenic shock and protection against haemodynamic instability during high-risk percutaneous coronary intervention (PCI). The intra-aortic balloon pump (IABP) is the current standard treatment for mechanical circulatory support. However, its efficacy seems limited, both in acute and elective settings. The Impella system is a new technique which may be a suitable alternative to IABP treatment. The Impella is a small micro-axial, catheter-mounted cardiac pump, which is inserted through the femoral artery. Safety and efficacy of Impella treatment have been demonstrated during elective high-risk PCI. In the setting of cardiogenic shock, mechanical support with the Impella may lead to partial recovery of left ventricular function, especially when Impella treatment is applied according to a carefully designed pre-specified protocol..
The intra-aortic balloon pump (IABP) has been a reliable friend in the catheterization laboratory and operating room. This good old friend of the cardiologist and cardiothoracic surgeon is about to disappear from the clinical scene. For more than 5 decades, it has largely been deployed for acute myocardial infarction and cardiogenic shock. Its more recent failure to demonstrate efficacy for cardiogenic shock will herald its demise. It may not disappear completely but its usage will become extremely limited. The lesson we have learned from the IABP history and other therapies is that we should never trust surrogate endpoints such as cardiac (power) output when it comes to cardiogenic shock. Newer devices should be tested in properly randomized controlled clinical trials before worldwide adoption.
