What is the optimal anticoagulation management of patients post-cardiac surgery who go into atrial fibrillation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether anticoagulation is indicated for patients in atrial fibrillation (AF) following coronary artery bypass grafting. Altogether 166 papers were found using the reported search, of which 10 presented the best evidence to answer the clinical question. In addition the American Heart Association guidelines for management of atrial fibrillation were reviewed. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that patients post-cardiac surgery require warfarinisation while in atrial fibrillation with an INR of 2-3, and full anticoagulation should be commenced within 48 h of the onset of AF as their risk of stroke is doubled by the onset of AF.     

Routine left atrial catheterization for the post-operative management of cardiac surgical patients: is the risk justified?

OBJECTIVE: To assess the risk/benefit ratio, including cost, associated with routine left atrial catheterization for the post-operative management of patients after cardiac surgery. METHODS: From November 1991 to June 1998, out of 6187 open heart procedures performed at our institution, 5815 patients (94%) receive a left atrial monitoring line inserted invasively by a unique and reproducible technique. Catheters were removed on the first or second postoperative day before chest tube removal. A subgroup of 385 patients (7%) were switched to a Swan-Ganz catheter postoperatively. RESULTS: A total of 14 patients suffered a complication related to the left monitoring line (0.24%). Bleeding necessitating transfusion occurred in 10 patients (0.17%), seven of whom required surgical reexploration (0.12%). Catheter retention occurred in four cases (0.07%), requiring a mediastinal reexploration in one and a minimally invasive procedures in three, for removal. No other complications related to the presence of a left atrial line emerged in this series. Apart from providing crucial hemodynamic information on a routine basis, in nine selected patients (0.15%) in a low cardiac output state with increased pulmonary vascular resistance and right ventricular failure, the left atrial line was used as a preferential route for catecholamine infusion, with significant hemodynamic improvement. CONCLUSIONS: Complications of left atrial monitoring catheters in cardiac surgery do occur but at a very low and acceptable rate. No mortality was correlated to their use in our series. Complication rate can be further lowered by a meticulous management of the device. The wealth of information and therapeutic options offered by this line appears to outweigh the associated risk.     

What is the optimal treatment for children with primary hyperparathyroidism?

Purpose

Little information exists regarding the optimal surgical treatment of pediatric primary hyperparathyroidism. We hypothesized that primary hyperparathyroidism in children, in the absence of a family history, is caused by single-gland disease and is amenable to minimally invasive parathyroidectomy (MIP).

Methods

We reviewed the records of individuals younger than 25 years who underwent parathyroidectomy in a prospectively collected database at a single tertiary hospital from 2003 to 2009.

Results

Twenty-five patients were identified, with a mean (SD) age of 19 (3.7) years. Sixty percent had single-gland disease (n = 15). Familial disease was present in 6 patients. All of the children younger than 18 years without a family history of disease (9/9) were found to have a single-gland disease (P < .001). Seventy-eight percent of patients without a family history were successfully treated without a bilateral exploration. Average length of stay was less than 1 day with no complications or recurrences.

Conclusions

Primary hyperparathyroidism in patients younger than 18 years without a family history was uniformly caused by single-gland disease. Minimally invasive parathyroidectomy was successful in these patients and avoided the morbidity of bilateral exploration. We recommend MIP be used in pediatric patients at large referral centers with prior successful institutional experience with the technique.     

What is essential for the elimination of persistent or chronic atrial fibrillation?

Dr. James Cox devised the maze procedure as a radical intervention for lone atrial fibrillation (AF) based on the multiple reentry theory. Dr. Micheal Haissaguerre discovered ectopic foci from the pulmonary veins were the trigger for paroxysmal AF. We demonstrated the efficacy of the pulmonary vein box isolation procedure for chronic AF. Dr. Koonlfawee Nademanee reported the complex fractionated atrial electrogram (CFAE) procedure to eliminate the substrate of chronic AF, which is distributed around the pulmonary veins. The complete isolation of all pulmonary veins is essential for the elimination of AF.     

How effective is cryoablation for atrial fibrillation during concomitant cardiac surgery?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether performing cryoablative procedures during concomitant cardiac surgical procedures is effective for the treatment of atrial fibrillation (AF). Altogether 291 papers were found using the reported search, of which nine 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. All studies showed that cryoablation during concomitant surgery had a significant effect on return to sinus rhythm (SR) conversion rate. One study showed that cryoablation was significantly more effective than mitral valve surgery alone at a 12-month follow-up (73.3% vs. 42.9%, respectively, P=0.013). The use of a concomitant cryoablative procedure has also been shown to be far superior to subsequent catheter based cryoablation in returning patients to SR at a 12-month follow-up (82% and 55.2%, respectively, P<0.001). Another study showed a significant return to AF over a three-year period (91.8% and 84.1% at discharge and three years, respectively). Return to SR was significantly decreased in those patients suffering from permanent rather than paroxysmal AF (47% vs. 85%, P<0.001). Paucity of level 1 evidence was a major limitation to this analysis. All nine papers were either small randomised controlled trials or retrospective studies with small sample sizes (57-521) and varied follow-up regimens. Six of nine studies suggested that cryoablation is most successful in patients suffering from paroxysmal rather than permanent AF. A lack of 24-h monitoring in seven of nine studies prevented effective elucidation of the rate of paroxysmal AF following cryoablation. Only one study suggested an increased complication rate from cryoablation, however, none suggested any negative impact on mortality or morbidity. We conclude that cryoablation during concomitant surgery is a safe and acceptable intervention for the treatment of AF with an SR conversion rate of between 60% and 82% at 12-months postsurgery.     

What are the predictors of restoration of sinus rhythm after combined treatment with surgical repair for organic heart disease and the Maze procedure for atrial fibrillation?

BACKGROUND: Recently, combined treatment using the Maze procedure for organic heart disease and atrial fibrillation has been reported, but there have been few studies of cardiac rhythm after combined treatment. Predictors of cardiac rhythm after combined surgical treatment have been unknown. METHODS: Thirty patients who underwent cardiac surgery with the Maze procedure were retrospectively enrolled in this study. Two groups consisted of the patients with restoration of sinus rhythm after surgery (SR: n=15, 6 males and 9 females, mean age of 64 years), and the patients with maintenance of atrial fibrillation (AF; n=15, 5 males and 10 females, mean age of 61 years). Before cardiac surgery, all patients underwent exercise testing with measurement of atrial natriuretic peptide (ANP) before and after exercise testing, two-dimensional echocardiography, and right and left heart catheterization. RESULTS: The mean maximal heart rate and the ANP level after exercise testing in SR were significantly higher than those in AF. The left atrial dimension and right atrial and pulmonary capillary wedge pressures were significantly higher in AF than in SR. These findings indicate that subjects in SR exhibited less impaired atrial function which were evaluated by exercise testing with measurement of ANP, echocardiography, and cardiac catheterization. CONCLUSIONS: The atrial function of patients with sinus rhythm after the Maze procedure may be less impaired than that of patients remaining in atrial fibrillation.     

What is the driving performance of ambulatory surgical patients after general anesthesia?

BACKGROUND: Ambulatory surgical patients are advised to refrain from driving for 24 h postoperatively. However, currently there is no strong evidence to show that driving skills and alertness have resumed in patients by 24 h after general anesthesia. The purpose of this study was to determine whether impaired driver alertness had been restored to normal by 2 and 24 h after general anesthesia in patients who underwent ambulatory surgery. METHODS: Twenty patients who underwent left knee arthroscopic surgery were studied. Their driving simulation performance, electroencephalographically verified parameters of sleepiness, subjective assessment of sleepiness, fatigue, alertness, and pain were measured preoperatively and 2 and 24 h postoperatively. The same measurements were performed in a matched control group of 20 healthy individuals. RESULTS: Preoperatively, patients had significantly higher attention lapses and lower alertness levels versus normal controls. Significantly impaired driving skills and alertness, including longer reaction time, higher occurrence of attention lapses, and microsleep intrusions, were found 2 h postoperatively versus preoperatively. No significantly differences were found in any driving performance parameters or electroencephalographically verified parameters 24 h postoperatively versus preoperatively. CONCLUSIONS: Patients showed lower alertness levels and impaired driving skills preoperatively and 2 h postoperatively. Based on driving simulation performance and subjective assessments, patients are safe to drive 24 h after general anesthesia.     

How effective is microwave ablation for atrial fibrillation during concomitant cardiac surgery?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether performing microwave ablative procedures during concomitant cardiac surgical procedures is effective for the treatment of atrial fibrillation (AF). In total, 200 papers were found using the reported search, of which 12 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. Major exclusion criteria included studies exclusively using bipolar ablation, ambiguous or unspecified ablation technique, other energy modalities and studies with highly variable or undisclosed follow-up time. One study reported that 66% of patients were in sinus rhythm (SR) with follow-ups ranging from 1 to 14 months and suggested that the risk of AF recurrence was significantly increased with a larger left atrial diameter (OR = 1.21, P = 0.02) and an increased duration of preoperative AF (OR = 2.14, P = 0.03). A separate study found no significant difference in the success rate on the basis of the concomitant procedure (coronary artery bypass grafting or mitral valve surgery, P > 0.5). In the only randomized trial identified, microwave ablation delivered significantly inferior SR restoration rates to radiofrequency (RF) ablation at all time points from discharge to 24 months. There is a large degree of heterogeneity in the studies, with patients' characteristics, for example type of AF, and patient management postoperatively, for example administration of anti-arrhythmias, being inconsistent. Of the 12 studies, nine assessed SR at a mean of 6-12 months and found postoperative success rates between 62 and 87%. One study looked at the medium range follow-up of 24 months with SR restoration at 71%. Two studies looked at the long-term follow-up (5 and 5.37 years) with SR restoration at 39 and 61%, respectively. We conclude that microwave ablation, as an intervention for the treatment of AF during concomitant surgery, is not currently recommended on the limited available evidence. This is because the success rates in the longer term are less clear and the only randomized study to date has found inferior outcomes compared with RF-based ablation.     

What is the biology and optimal treatment for papillary microcarcinoma of the thyroid?

BACKGROUND: Papillary microcarcinomas of the thyroid, defined as tumors measuring < or =10 mm, are believed to be a less aggressive subset of papillary cancers that behave more like benign lesions and are often more conservatively treated. However, some groups have reported a high incidence of metastases from papillary microcarcinomas and favor aggressive surgical resection followed by radioiodine therapy. Therefore, to characterize the biology and optimal treatment for papillary microcarcinomas, we reviewed our experience. METHODS: From May 1994 to October 2004, 184 patients underwent thyroid surgery at the University of Wisconsin and had papillary thyroid cancer present in the resected gland. Of these patients, 10 were excluded because there was no record of tumor size. Of the remaining 174 patients, 74 (42%) had papillary microcarcinomas. Data from these patients were retrospectively analyzed. RESULTS: The mean age of these patients was 42 +/- 1.48 year and 57 (77%) were female. The mean tumor size was 5.7 +/- 0.38 mm. Of the 74 patients, 12 (16%) had lymph node metastases. The majority of patients (65%) underwent a total thyroidectomy and 61% had radioiodine ablation therapy after surgery. With follow-up up to 134 months, the recurrence rate was 8% and only two patients currently have active disease. No patients with papillary microcarcinoma have died during this period. CONCLUSION: Papillary microcarcinomas of the thyroid are quite common, comprising almost half of all papillary cancers. Despite a significant rate of metastatic disease, the prognosis for patients with microcarcinomas has been excellent with 100% survival and a low recurrence rate. These outcomes may be the result of the aggressive surgical therapy used at our institution. Thus, papillary microcarcinomas appear to have a similar biology to other low risk papillary thyroid cancers and, in our opinion, may warrant similar treatment.     

Does magnesium offer any additional benefit in patients having anti-arrhythmic treatment for atrial fibrillation following cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether treatment with magnesium in addition to an anti-arrhythmic is beneficial to patients who have gone into atrial fibrillation after cardiac surgery. Altogether 466 papers were identified using the below mentioned search, of which 8 papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that while the literature on magnesium prophylaxis and non-cardiac surgical studies on magnesium therapy for atrial fibrillation suggest that magnesium may be of benefit, there are currently no studies in post-cardiac surgery atrial fibrillation to support the use of magnesium therapy for these patients.     

How effective is bipolar radiofrequency ablation for atrial fibrillation during concomitant cardiac surgery?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether, in patients undergoing cardiac surgery, concomitant bipolar radiofrequency ablation had an acceptable success rate to justify the additional procedure. Altogether 263 papers were found using the reported search, of which 12 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 consensus in the literature was that bipolar radiofrequency ablation was highly successful in restoring sinus rhythm. One meta-analysis of six non-randomized studies demonstrated that 76% of patients were in sinus rhythm compared with 16% in atrial fibrillation 3 months postoperatively. One randomized controlled trial found that the sinus rhythm conversion rate for any maze procedure was highly significant compared with the control group (P?=?0.001). Another found that Cardioblate radiofrequency ablation was significantly better at restoring sinus rhythm at 1 year (75 vs 39% control, P?=?0.019). Prospective studies showed a similar rate of sinus rhythm return at 1 year (89%). Notably some studies demonstrated a significant reduction in the New York Heart Association class when sinus rhythm was restored compared with those remaining in atrial fibrillation (P?相似文献   

What is the optimal treatment for lower ureteral stones larger than 1cm?

PURPOSE: To compare the treatment options for lower ureteral stones larger than 1 cm. METHODS: The records of 449 patients with lower ureteral calculi larger than 1 cm were reviewed retrospectively. Of these patients 342 (76.1%) were treated with extracorporeal shock wave lithotripsy (ESWL) (group 1), 66 (14.7%) with pneumatic lithotripsy (PL) (group 2) and 128 (28.5%) with ureterolithotomy (group 3). Eighty-seven (19.5%) patients underwent any of the two treatment modalities because of unsuccessful primary treatment. RESULTS: The overall stone-free rates were 32.4, 90.9 and 95.3% for ESWL, PL and ureterolithotomy, respectively. These values were 84.4% for primary PL and 96.7% for primary ureterolithotomy. The re-treatment rate (46.4%) and secondary procedures were much more frequent in the ESWL group. There was no difference in the complication rates of the three groups. CONCLUSIONS: Pneumatic lithotripsy with ureteroscopy seems to be an appropriate treatment for larger ureteral stones. While ESWL can be tried as a first treatment option because of its noninvasive nature, lower success and higher re-treatment rates limit its usefulness. Ureterolithotomy is still a reasonable alternative for these large or unfragmented stones.     

What is the role of biomarker measurement after cardiac surgery?

Measurements of cardiac troponin (cTn) and natriuretic peptides can predict outcomes after cardiac surgery and may thus assist in decision making about diagnostic and therapeutic steps in this setting. Not every cardiac surgical procedure is associated with the same degree of cTn or natriuretic peptide elevation; the factors known to affect concentrations of these markers include the severity of preoperative coronary artery disease as well as presenting syndrome, while forms of cardioprotection and anesthesia may affect postoperative concentrations of biomarkers. Release of cTn appears to represent irreversibly damaged myocardium; however, clinicians are cautioned when measuring cTn in post-cardiac surgery venues not to assume an elevated concentration is equivalent to regional acute myocardial infarction; indeed, more often than not, excessive values of cTnT or cTnI more typically represent diffuse myocardial injury. Natriuretic peptide release may occur through both states of irreversible dysfunction as well as more reversible states, such as postoperative shock. Indeed, both cTn and natriuretic peptides are unequivocally prognostic for delayed recovery, intensive care unit utilization, as well as short- and longer-term mortalities following cardiac surgery.