Sternal dehiscence after cardiac surgery and ACE inhibitors [correction of ACE type 1 inhibition].

We report two cases, which underwent surgery through Median sternotomy. They were on ACE inhibitors [corrected] pre-operatively. Both of these patients developed persistent dry cough post-operatively, which resulted in sternal wound dehiscence. They had no clinical or bacteriological evidence of sternal wound infection. Although one patient was overweight and had moderately impaired left ventricular function, there were no other associated risk factors. Both patients underwent rewiring of the sternum. Type II receptors inhibitor were introduced post-rewiring, which cured the persistent dry cough. Both the patients are enjoying a good quality of life at 2 year 6 months and 2 years post-rewiring of the sternum.     

Gastrointestinal complications after cardiac surgery.

Gastrointestinal complications after cardiac surgery are uncommon, but are associated with a high morbidity and mortality. Over 11 years 8559 procedures requiring cardiopulmonary bypass were performed in this unit and 35 patients were identified who developed gastrointestinal complications after surgery, an incidence of 0.41%. There were nine deaths in this group, a mortality of 25.7% compared with an overall mortality after cardiac surgery in Ireland ranging from 3.24% to 4.81%. These complications required surgery in 21 patients. The most common indication for surgical intervention was upper gastrointestinal bleeding in 10 patients, three patients had acute pancreatitis, two patients had perforated peptic ulcer; two patients had intestinal ischaemia, with five cases of colon pathology. The difficulties of making an early diagnosis are outlined and a low threshold to exploratory laparotomy is recommended.     

ICU readmission after cardiac surgery.

OBJECTIVES: The increasing cost of intensive care unit (ICU) care and limited resources lead us to evaluate predictors of ICU readmission in a large group of patients undergoing coronary artery bypass surgery (CABG) at one institution. METHODS: Two thousand one hundred and seventeen consecutive patients undergoing CABG surgery between January 1999 and August 2001 were reviewed retrospectively. The reasons for readmission were determined by reviewing the physician's progress notes, the nurse's progress notes and the discharge summary. RESULTS: A total of 75 patients were readmitted to ICU during the study period for a readmission rate of 3.6%. Eight of these were readmitted a second time, and three a third time, for a total of 86 readmissions. Forty-seven patients died, for a mortality of 2% among patients that were not readmitted to the ICU, compared to 17% among those who were readmitted (P<0.0001). Median hospital length of stay was 6 days for patients not readmitted and 23 days for those readmitted (P<0.0001). The most common reason for readmission was respiratory failure, accounting for 47% of readmissions (n=40). Multivariate analysis using a stepwise logistic regression analysis revealed that preoperative renal failure (odds ratio 2.13; CI 1.03-4.41) and prolonged mechanical ventilation of >24 h (odds ratio 10.52; CI 6.18-17.91) were the only independent predictors for readmission to the ICU after CABG. CONCLUSIONS: Identification of patients that have preoperative renal failure or that required initial ventilation for more than 24 h after CABG may help to identify patients at risk of ICU readmission. Preemptive strategies designed to optimize these high-risk patients may improve outcomes.     

Intra-abdominal complications after cardiac surgery.

Gastrointestinal complications such as peptic ulcer disease, pancreatitis, acute cholecystitis, bowel ischaemia, and diverticulitis are rare after cardiac surgery (< 1%), but are associated with high morbidity and mortality (about 30%). Hypoperfusion during cardiopulmonary bypass seems a possible aetiological factor. As many patients may be mechanically ventilated and sedated, the usual symptoms and signs of an abdominal complication may be masked. It is necessary to keep this possibility in mind in patients with abdominal pain or tenderness, and the usual diagnostic measures should be undertaken if time permits. Initial treatment is usually conservative, but when it fails, prompt intervention is obligatory. Unfortunately surgeons are often reluctant to submit patients to major abdominal operations immediately after cardiac surgery. However, effective and timely intervention may be life-saving in patients who are poorly able to compensate for the major haemodynamic disturbances of the untreated serious bleeding or sepsis. Although the cardiac condition must be taken into consideration, most patients' cardiac function will have improved since their open-heart surgery and they should be able to withstand general anaesthesia and most operations.     

Vasomotor dysfunction after cardiac surgery.

Cardiopulmonary bypass and cardioplegic arrest, which allow for support of the circulation and stabilization of the heart during cardiac procedures, are still used for the vast majority of cardiac operations worldwide. However, in addition to a well-recognized systemic inflammatory response, cardiopulmonary bypass and cardioplegic arrest elicit complex, multifactorial vasomotor disturbances that vary according to the affected organ bed, with reduced vascular resistances in the skeletal muscle and peripheral circulation, and increased propensity to spasm in the cardiac, pulmonary, mesenteric and cerebral vascular beds. This article outlines the nature, mechanistic basis, and clinical correlates of the vasomotor alterations encountered in patients undergoing cardiac surgery using cardiopulmonary bypass and cardioplegic arrest.     

Metabolic alkalosis after pediatric cardiac surgery.

OBJECTIVE: To determine occurrence, causes and associated mortality of postoperative metabolic alkalosis in pediatric cardiac surgery. METHODS: We retrospectively analyzed clinical and biochemical variables of 186 consecutive cardiac operations other than ductal ligations on children less than 2 years old during the years 1999 and 2000. Metabolic alkalosis was defined as a pH>7.48 corrected for PCO2, with a base excess > or =5 on two or more consecutive measurements during an 8h period. RESULTS: Median age was 15 weeks [range 2 days-95 weeks] and median weight 4.5 kg [range 2.1-15.7 kg]. In 157 cases, cardiopulmonary bypass was used. In 92 [49%] procedures, metabolic alkalosis occurred with the highest corrected pH 24.3h after operation. Multivariate regression analysis associated age [P<0.001], cardiopulmonary bypass [P<0.001] and preoperative ductal dependency [P=0.04] with postoperative metabolic alkalosis. Of the surgical procedures the arterial switch for transposition of the great arteries [n=19] was strongly associated with metabolic alkalosis [100%, P<0.001]. Hemodilution appeared to enhance the development of alkalosis: those who experienced alkalosis had been hemodiluted to a greater extent [P=0.007]. Nearly 95% of patients experienced some increase in bicarbonate, but patients with metabolic alkalosis experienced more than those without [5.9 versus 3.5 mmol/l, P<0.001]. There were four postoperative deaths, only one coincidental with metabolic alkalosis. CONCLUSIONS: Metabolic alkalosis has a high incidence after pediatric cardiac surgery, strongly associated with younger age, cardiopulmonary bypass, preoperative ductal dependency and perioperative hemodilution. Early recognition allows for timely therapeutic intervention.     

Cytomegalovirus-induced haemolytic anaemia after cardiac surgery.

A patient, who underwent aortic valve replacement, developed a transient, autoimmune haemolytic anaemia in association with a significant rise in titre of antibodies against cytomegalovirus. A serological survey of blood donors indicated that the source of infection was fresh blood transfused during and shortly after surgery. A number of cases of short-lived haemolytic anaemia after large volume blood transfusion with cardiac surgery may be explained by this mechanism. It may be preferable to use only blood that has been screened for evidence of recent cytomegalovirus infection if post-perfusion complications of this disease are to be avoided.     

Myocardial infarct imaging after cardiac surgery.

One hundred and nineteen patients undergoing cardiac surgery had postoperative myocardial imaging performed with technetium pyrophosphate in order to assess the incidence of perioperative myocardial infarction. Fifty-six patients had only coronary artery bypass graft (CABG) surgery, of whom 13(23%) had a positive scintigram. Thirteen patients had CABG with other cardiac surgery and six (46%) had a positive scintigram. Fifty patients had other cardiac surgery but no CABG, and of these eight (16%) had a positive scintigram. The overall incidence of positive scintigrams was 23%, whereas definite or probable ECG diagnosis of infarction was present in 14 patients (12%). Serum levels of cardiac enzymes were higher in patients with positive scintigrams, but this finding did not consistently reach statistical significance. The use of a left ventricular vent during surgery did not correlate with a positive scintigram, nor did the total time on cardiopulmonary bypass or aortic cross-clamping. Patients having cardiac surgery, including CABG and valve replacement, have a 23% overall incidence of positive scintigrams. This suggests that the incidence of infarction after cardiac surgery is higher than can be recognized from the conventional criteria of ECG and enzyme changes.     

Renoprotection by ACE inhibitors after severe hemolytic uremic syndrome

Five patients with severe hemolytic uremic syndrome (HUS) were followed for 10–18 years. Because of proteinuria, arterial hypertension, and reduced glomerular filtration rates, they received either captopril (n=2) or enalapril (n=3), or both (n=1) for 8–15 years. Blood pressure was normalized and proteinuria reduced in all; glomerular filtration improved in three patients and fell moderately in two. Four of the five patients have reached adult age with body weight and height, blood pressure, and serum creatinine levels within the normal range. At the last evaluation, median proteinuria was 220 mg/24 h (range 0–310) and glomerular filtration rate 56 ml/min per 1.73 m² (range 40–127). This long-term study indicates a renoprotective effect of angiotensin-converting enzyme inhibitors in patients with sequelae after HUS.