Perioperative management of a patient with May-Hegglin anomaly requiring craniotomy

May-Hegglin anomaly (MHA) is a rare type of autosomal dominant platelet disorder associated with mutations in the gene encoding nonmuscle myosin heavy chain 9 (MYH9). It is characterized by the presence of large platelets, leukocyte inclusions, and thrombocytopenia. The bleeding tendency is usually mild, but severe hemorrhages have been reported. This is the first reported case of a patient with MHA who underwent craniotomy for intractable seizure disorder of temporal lobe origin. Patients who have thrombocytopenia have a higher likelihood of developing intraoperative or postoperative intracranial hematoma and bleeding complications. The patient was administered desmopressin (DDAVP) prior to the neurosurgical procedure and had no complications. With this approach, the use of platelet concentrates could be avoided. We discuss the role of DDAVP in MHA and related platelet disorders and review the current literature.     

Perioperative intra-aortic balloon counterpulsation in a patient with myocardium at risk undergoing urgent noncardiac surgery

We are presenting the case of a 76-year-old female scheduled for major abdominal surgery. Her past medical history was remarkable for a three-vessel coronary artery disease, with a severely impaired left ventricular function. She had already undergone complex coronary artery bypass surgery. Currently, she presented with the rare constellation of a hemodynamic relevant and interventionally intractable stenosis of the left subclavian artery proximal to a crucial coronary bypass from left internal mammary artery to the left anterior descending. To protect this patient from perioperative myocardial infarction, an intra-aortic balloon pump was successfully used.     

The virtual histology intravascular ultrasound appearance of newly placed drug-eluting stents

Intravascular ultrasound (IVUS) is used before and after intervention and at follow-up to assess the quality of the acute result as well as the long-term effects of stent implantation. Virtual histology (VH) IVUS classifies tissue into fibrous and fibrofatty plaque, dense calcium, and necrotic core. Although most interventional procedures include stent implantation, VH IVUS classification of stent metal has not been validated. In this study, the VH IVUS appearance of acutely implanted stents was assessed in 27 patients (30 lesions). Most stent struts (80%) appeared white (misclassified as "calcium") surrounded by red (misclassified as "necrotic core"); 2% appeared just white, and 17% were not detectable (compared with grayscale IVUS because of the software-imposed gray medial stripe). The rate of "white surrounded by red" was similar over the lengths of the stents; however, undetectable struts were mostly at the distal edges (31%). Quantitatively, including the struts within the regions of interest increased the amount of "calcium" from 0.23 +/- 0.35 to 1.07 +/- 0.66 mm(2) (p <0.0001) and the amount of "necrotic core" from 0.59 +/- 0.65 to 1.31 +/- 0.87 mm(2) (p <0.0001). Most important, because this appearance occurs acutely, it is an artifact, and the red appearance should not be interpreted as peristrut inflammation or necrotic core when it is seen at follow-up. In conclusion, acutely implanted stents have an appearance that can be misclassified by VH IVUS as "calcium with or without necrotic core." It is important not to overinterpret VH IVUS studies of chronically implanted stents when this appearance is observed at follow-up. A separate classification for stent struts is necessary to avoid these misconceptions and misclassifications.     

Perioperative management of patients with coronary stents

Perioperative coronary stent thrombosis is a catastrophic complication that can occur in patients receiving both bare-metal and drug-eluting stents. Noncardiac surgery appears to increase the risk that recently-placed stents thrombose, especially when surgery is performed early after stenting, and particularly if dual antiplatelet therapy is discontinued. We reviewed the existing data about the frequency of stent thrombosis after noncardiac surgery and explored the impact of delay from surgery and discontinuation of antiplatelet therapy. We also reviewed the data about the impact of preoperative revascularization in patients known to require noncardiac surgery. Based on these published data, we offer recommendations that can be used to guide the treatment of patients who require noncardiac surgery after having received a stent.     

Perioperative management of patients with coronary stents.

Perioperative coronary stent thrombosis is a catastrophic complication that can occur in patients receiving both bare-metal and drug-eluting stents. Noncardiac surgery appears to increase the risk that recently-placed stents thrombose, especially when surgery is performed early after stenting, and particularly if dual antiplatelet therapy is discontinued. We reviewed the existing data about the frequency of stent thrombosis after noncardiac surgery and explored the impact of delay from surgery and discontinuation of antiplatelet therapy. We also reviewed the data about the impact of preoperative revascularization in patients known to require noncardiac surgery. Based on these published data, we offer recommendations that can be used to guide the treatment of patients who require noncardiac surgery after having received a stent.     

A propensity score matched analysis to determine if second-generation drug-eluting stents outperform first-generation drug-eluting stents in a complex patient population

Background

Drug-eluting stents (DES) are routinely used in complex patients, but the impact of 1st- versus 2nd-generation DES on clinical outcomes has not been well described. This study aimed to assess the efficacy and safety of 2nd-generation (everolimus-eluting) DES compared to 1st-generation (sirolimus- and paclitaxel-eluting) DES in a selected, higher-risk population with complex clinical and angiographic features.

Methods

The study included 5693 consecutive patients with the presence of ≥ 1 predefined complex clinical and angiographic characteristic treated with either generation DES. Using propensity score matching, the clinical outcomes of 1076 patients treated with 2nd-generation DES were compared with the outcomes of a matched population treated with 1st-generation DES over 1-year follow-up.

Results

After matching, baseline clinical and angiographic characteristics were similar between groups. At 1-year follow-up, the rate of major adverse cardiac events was 9.4% with 2nd-generation DES and 11.3% with 1st-generation DES (p = 0.16). There were no significant differences in the rates of death (3.2 vs. 4.0%, p = 0.30), myocardial infarction (1.6 vs. 1.3%, p = 0.57), target vessel revascularization (5.9 vs. 7.3%, p = 0.17) or target lesion revascularization (4.4 vs. 5.0%, p = 0.50). Definite stent thrombosis was less frequent with 2nd-generation DES (0.1 vs. 0.8%, p = 0.011), as was definite or probable stent thrombosis (0.7 vs. 1.6%, p = 0.040).

Conclusion

In this propensity score matched patient population with complex features undergoing percutaneous coronary intervention, the use of 2nd-generation DES was associated with lower rates of stent thrombosis, and similar 1-year major adverse cardiac events compared to 1st-generation DES.     

Perioperative management of a patient with Fechtner syndrome

Fechtner syndrome is a rare type of familial thrombocytopenia associated with large platelets, leukocyte inclusions, and features of Alport's syndrome. The bleeding tendency is usually mild, but severe hemorrhages have been reported. This is the case of a patient with Fechtner syndrome who was scheduled to undergo tonsillectomy. The patient had a history of easy bruising in childhood and a markedly prolonged bleeding time. Administration of DDAVP led to normalization of the bleeding time, and the patient underwent surgery without complications. With this approach the use of platelet concentrates could be avoided.     

Perioperative management of the diabetic patient in cardiac surgery with extracorporeal circulation

The hyperglycemia usually observed in patients undergoing heart surgery with extracorporeal circulation (EC) represents a difficult therapeutic problem. We studied the effects of several regimens of insulin therapy on serum glucose (SG) in 24 noninsulin dependent diabetic patients (NIDDs). The patients were randomly divided in five groups; group A received on IV bolus of 10.0-50.0 U/h according to glycosuria; groups B, C, D and E were given a continuous iv insulin infusion of 2.5, 5.0, 7.5 and 10.0 U/h respectively. In 10 non-diabetic patients (NDP) SG levels were also measured, but insulin was not given. A mean of 5.0 l/m2 of body surface of fluids containing 300 g of glucose were administered to all patients during surgery. At the operations SG levels rose progressively soon after the anesthesia was started, reached the highest values during the period of EC, and decreased slowly in blood samples taken after the EC phase and by 24h. This patterns was shown by all groups studied statistically significant lower SG levels, however, were observed in patients of group C, whose values were similar to those seen in the NDP group. Groups D and E had slightly higher SG levels than those of group C. An additional NIDDM patient with advanced chronic renal failure (CRF), had a tendency to hypoglycemia even during the EC period in response to relatively low doses of insulin (2.5 U/h), given by a continuous iv infusion and, although the insulin administration was stopped, his SG levels remained well below the mean values of the other patients for the rest of the operation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Analysis of 36 reported cases of late thrombosis in drug-eluting stents placed in coronary arteries

Drug-eluting stents (DESs) have decreased the incidence of in-stent restenosis. Within the past 2 years several cases on late stent thrombosis (LST) have been reported. This study analyzed and reviewed all published cases of LST in DESs to explore possible trends not previously reported. We applied a Medline search using the key word "drug eluting stents." All 845 positive matches in March 2006 were screened for case reports of LST in DESs, defined as angiographic stent thrombosis >or=30 days after deployment. We included reported LSTs from randomized trials, observational registry reports, and letters to the editor if information regarding timing from stent deployment to clinical event, vessel, stent diameter and length, and antiplatelet regimen were available. There was no significant difference in the incidence of LST between sirolimus- and paclitaxel-eluting stents. Median time from stent deployment to clinical event was 242 days (total range 39 to 927). If aspirin and clopidogrel were discontinued, median time to clinical event was 7 days (3 to 150). In comparison, if only clopidogrel was discontinued, median time to clinical event was 30 days (14 to 690, p <0.0001). There was no significant difference in stent diameter and length between sirolimus- and paclitaxel-eluting stents. Forty-two percent of events occurred in relation to a surgical procedure for which the 2 antiplatelet agents or clopidogrel alone was discontinued. In conclusion, there was a strong association between occurrence of LST and cessation of dual antiplatelet therapy. Patients who continued on aspirin had a significant delay to the clinical event. Efforts should be made to maintain patients on aspirin during routine surgical procedures.     

Symptomatic coronary patient with pathological coronary angiogram requiring surgery

Bypass surgery has become a routine procedure for the treatment of coronary artery disease. Due to increase numbers of high-risk patients minimally invasive techniques were introduced in cardiac surgery with excellent clinical results. In addition molecular methods have been applied for primary and secondary treatment of coronary artery disease.