A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'What is the value of topical cooling as an adjunct to myocardial protection?' Using the reported search, 9 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The studies included four randomized controlled trials (RCTs). Two RCTs demonstrated no cardioprotective effects of topical hypothermia as they found no statistically significant differences in myocardial markers between patients with or without topical cooling. In a randomized study of 249 patients undergoing elective cardiac surgery, phrenic nerve injury and failure of extubation occurred more frequently with the use of topical hypothermia with iced slush (P = 0.009 and P = 0.034, respectively). One retrospective analysis found that patients who received iced topical hypothermia had longer postoperative hospitalization, higher incidence of atelectasis and higher left diaphragms on chest X-ray. Another study showed increased morbidity and mortality associated with postoperative diaphragmatic dysfunction resulting from the use of iced slush topical cooling of the heart. We conclude that topical cooling is an unnecessary adjunct to myocardial protection in patients undergoing cardiac surgery. There is no evidence of any additional cardioprotective benefit. Several studies showed that the use of topical hypothermia is associated with phrenic nerve injury, leading to diaphragmatic paralysis and increased pulmonary complications. Moreover, long-term follow-up data showed often incomplete regression of the phrenic nerve paralysis. However, few randomized studies exist on the value of topical cooling as an adjunct to myocardial protection.
Acute kidney injury (AKI) is a common complication after surgical aortic valve replacement and is associated with increased mortality. Transcatheter aortic valve implantation (TAVI) is now considered the criterion standard treatment of patients with severe symptomatic aortic stenosis ineligible for surgery. The aim of this study was to establish the incidence, risk factors, and prognostic consequences of AKI after TAVI and at 1-year follow-up in a single center.Between December 2007 and March 2011, a total of 79 patients with severe aortic stenosis who underwent 81 TAVI procedures with the Medtronic CoreValve System or the Edwards SAPIEN heart valve were included. Baseline characteristics and procedural complications were recorded. Acute kidney injury was defined according to the Valve Academic Research Consortium criteria (modified risk, injury, failure, loss, and end-stage kidney disease criteria).The mean age was 84 (78-87) years; 49 were men. After TAVI, 10 patients (12.3%) developed AKI, which had completely resolved in 9 patients before hospital discharge. Nine patients (10%) had mild AKI (stage 1) and only one patient (10%) experienced moderate AKI (stage 2) according to Valve Academic Research Consortium definitions. The predictive factors of AKI were diabetes (odds ratio, 6.722; P = 0.004) and preoperative creatinine level greater than 104 μmol/L (odds ratio, 1.024; P = 0.02). Thirteen patients (16.4%) died within 1 year after TAVI. Three of the nonsurvivors (3.7%) developed AKI postoperatively. Acute kidney injury was, however, not a predictive factor of 1-year mortality after TAVI.Acute kidney injury occurred in 12.3% of the patients after TAVI and persisted in only one patient before hospital discharge. Diabetes and preoperative creatinine level were found to be the main predictive factors of AKI after TAVI. Acute kidney injury was not associated with increased 1-year mortality.
Acute kidney injury (AKI) is a common complication after surgical aortic valve replacement and is associated with increased mortality. Transcatheter aortic valve implantation (TAVI) is now considered the criterion standard treatment of patients with severe symptomatic aortic stenosis ineligible for surgery. The aim of this study was to establish the incidence, risk factors, and prognostic consequences of AKI after TAVI and at 1-year follow-up in a single center.Between December 2007 and March 2011, a total of 79 patients with severe aortic stenosis who underwent 81 TAVI procedures with the Medtronic CoreValve System or the Edwards SAPIEN heart valve were included. Baseline characteristics and procedural complications were recorded. Acute kidney injury was defined according to the Valve Academic Research Consortium criteria (modified risk, injury, failure, loss, and end-stage kidney disease criteria).The mean age was 84 (78-87) years; 49 were men. After TAVI, 10 patients (12.3%) developed AKI, which had completely resolved in 9 patients before hospital discharge. Nine patients (10%) had mild AKI (stage 1) and only one patient (10%) experienced moderate AKI (stage 2) according to Valve Academic Research Consortium definitions. The predictive factors of AKI were diabetes (odds ratio, 6.722; P = 0.004) and preoperative creatinine level greater than 104 μmol/L (odds ratio, 1.024; P = 0.02). Thirteen patients (16.4%) died within 1 year after TAVI. Three of the nonsurvivors (3.7%) developed AKI postoperatively. Acute kidney injury was, however, not a predictive factor of 1-year mortality after TAVI.Acute kidney injury occurred in 12.3% of the patients after TAVI and persisted in only one patient before hospital discharge. Diabetes and preoperative creatinine level were found to be the main predictive factors of AKI after TAVI. Acute kidney injury was not associated with increased 1-year mortality.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'which patients should be on renin-angiotensin system blockers after coronary surgery?' Using the reported search, 12 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The 12 studies included 5 prospective randomized controlled trials (RCTs) and 1 meta-analysis. One RCT of 2553 stable patients post-coronary artery bypass surgery (CABG) with left ventricular (LV) ejection fraction ≤40% showed that angiotensin-converting enzyme inhibition (ACEI) therapy can and probably should be delayed beyond 7 days due to increased cardiovascular morbidity and mortality associated with immediate postoperative initiation of ACEI treatment. Another study showed that the cardioprotective benefits of ACEI following CABG are persistent with respect to an LV ejection fraction below or above 40% and whether percutaneous coronary intervention (PCI) or CABG was performed. A large multicentre international study of 4224 patients undergoing CABG looking at a composite outcome of rates of cardiac, cerebral and renal events and in-hospital mortality showed that continuous treatment with ACEI compared with no ACEI was associated with reductions of risks of non-fatal events (P = 0.009, odds ratio 0.69, 95% confidence interval 0.52–0.91). Addition of ACEI de novo following surgery was also associated with significant reduction in the risk of the composite outcome (P = 0.004) and of a cardiovascular event (P = 0.04). We conclude that angiotensin-converting enzyme inhibitor treatment plays an important role in minimizing ischaemic events after CABG even in low-risk patients. The cardioprotective benefits of these drugs are persistent at mid- and long-term follow-up, with respect to LV ejection fraction below or above 40% and whether PCI or CABG was performed. Not only continuation of angiotensin-converting enzyme inhibition early after surgery but also adding ACEI de novo postoperatively can be associated with better cardiovascular and renal outcomes.
Lobar torsion is a rare but life-threatening complication after lung resection. We report a case of left lower lobe torsion in 57-year-old women after upper lobectomy for underlying lung cancer. Definitive diagnosis of lung torsion was made at exploratory thoracotomy following abnormal chest radiography and bronchoscopy on the first post-operative day. An emergency completion pneumonectomy was performed and left lower lobe was resected. The post-operative course was uncomplicated and patient was discharged home on the seventh post-operative day. Early recognition and prompt treatment of lobar torsion is essential for preventing potentially catastrophic complications including fatal gangrene of the pulmonary lobe.
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