Emergency coronary artery surgery after refractory cardiac arrest: a single centre experience.

OBJECTIVE--To determine the incidence and outcome of refractory cardiac arrest necessitating emergency coronary artery bypass grafting. DESIGN--Retrospective survey of cardiac catheterisation and surgical records. SETTING--The London Chest Hospital. PATIENTS--All patients requiring emergency coronary artery bypass grafting after cardiovascular collapse in the catheterisation suite between January 1984 and December 1989. MAIN OUTCOME MEASURES--Incidence of refractory cardiac arrest in the study group and perioperative mortality. RESULTS--Thirteen of 8675 patients undergoing coronary arteriography or angioplasty had refractory cardiac arrests. Five patients died, but the remainder survived to be discharged from hospital without serious morbidity. CONCLUSION--Without immediate surgical intervention the mortality for these 13 patients would have been 100%.     

Noninvasive diagnosis of coronary artery fistula after cardiac surgery

A 5-year-old boy underwent ventricular septal defect closure as well as resection of the muscle bundle of a double-chamber right ventricle and a subaortic membrane. Five days after surgery, echocardiography revealed a left anterior descending artery fistula with 2 sites of entry to the right ventricle. The child was asymptomatic with no murmurs. Echocardiography is an excellent tool for detecting such silent clinical lesions.     

Patient outcomes after total pancreatectomy: a single centre contemporary experience

Introduction:

Total pancreatectomy (TP) is associated with significant metabolic abnormalities leading to considerable morbidity. With the availability of modern pancreatic enzyme formulations and improvements in control of diabetes mellitus, the metabolic drawbacks of TP have diminished. As indications for TP have expanded, we examine our results in patients undergoing TP.

Materials and methods:

Retrospective study of 47 patients undergoing TP from January 2002 to January 2008 was performed. Patient data and clinical outcomes were collected and entered into a database. Disease-free survival and overall survival were estimated using the Kaplan–Meier method.

Results:

Fifteen males and 32 females with a median age of 70 years underwent TP for non-invasive intraductal papillary mucinous neoplasms (IPMN) (21), pancreatic adenocarcinoma (20), other neoplasm (3), chronic pancreatitis (2) and trauma (1). Median hospital stay and intensive care stay were 11 days and 1 day, respectively. Thirty-day major morbidity and mortality was 19% and 2%, respectively. With a median follow-up length of 23 months, 33 patients were alive at last follow-up. Estimated overall survival at 1, 2 and 3 years for the entire cohort was 80%, 72% and 65%, and for those with pancreatic adenocarcinoma was 63%, 43% and 34%, respectively. Median weight loss at 3, 6 and 12 months after surgery was 6.8 kg, 8.5 kg and 8.8 kg, respectively. Median HbA1c values at 6, 12 and 24 months after surgery were 7.3, 7.5 and 7.7, respectively. Over one-half of the patients required re-hospitalization within 12 months post-operatively.

Conclusion:

TP results in significant metabolic derangements and exocrine insufficiency, diabetic control and weight maintenance remain a challenge and readmission rates are high. Survival in those with malignant disease remains poor. However, the mortality appears to be decreasing and the morbidities associated with TP appear acceptable compared with the benefits of resection in selected patients.     

Emergency response time after out-of-hospital cardiac arrest

Objectives

To investigate the emergency response time after out-of-hospital cardiac arrest (OHCA) in four cities in Serbia.

Methods

A prospective, two-year, multicenter study was designed. Using the Utstein template we recorded out-of-hospital CPR (OHCPR) and analyzed the time sequence segment of the variables in OHCA and CPR gold standards. Multivariable logistic regression models were developed using emergency response time as the primary independent variable and survival to return of spontaneous circulation (ROSC), survival to hospital discharge (HD), and one-year survival (1y) as the dependent variable. ROC curves represent cut off time dependent survival data.

Results

During the study period, the median time of recognition OHCA was 5.5 min, call receipt was 1 min and the call-response interval was 7 min. The median time required to verify OHCA and ALS onset was 10 min. ALS was carried on for 30.5 min (SD = 21.3). Abandonment of further CPR/death occurred after 29 min. The first defibrillation shock was performed after 13.3 ± 9.0 min, endotracheal tube was placed after 16.8 ± 9.4 min and the first adrenaline dose was injected after 18.9 ± 9.3 min. Higher survival (ROSC, HD, 1y) rate was found when CPR is performed within the first 4 min after OHCA.

Conclusion

The emergency response time within 4 min was associated with improved survival to ROSC, HD and 1y after OHCA. Despite the fact that our results are in accordance with the findings published in other papers, there is still a need to take all appropriate measures in order to decrease the emergency response time after OHCA.     

Reduction in hospitalization rates following cardiac resynchronisation therapy in cardiac failure: experience from a single centre.

AIMS: Frequent, lengthy hospital admissions for congestive cardiac failure (CCF) result in excessive health care costs. Cardiac resynchronisation therapy (CRT) is a novel treatment option for patients with CCF and associated cardiac conduction defects. We investigated whether CRT resulted in significant improvements in New York Heart Association (NYHA) symptom class, exercise tolerance, and hospitalization rates in such patients. METHODS: Twenty-seven patients who underwent CRT in a single centre were studied, with NYHA symptom class, exercise tolerance and hospitalization rates noted in the 12 months prior to and following CRT. RESULTS: Following 12 months of CRT, NYHA symptom class improved from 3.3 +/- 0.5 to 2.1 +/- 0.4 (P < 0.05). Exercise tolerance, assessed by 6 min hall walk test increased by 64% from 195 +/- 114 m to 320 +/- 85 m (P = 0.007). Days in hospital for stabilisation of cardiac failure decreased by 98% from 472 to 9 days (P < 0.001). Significant hospitalization cost savings of 201,684 euros were calculated, with an overall saving of 12,420 euros. CONCLUSIONS: These data demonstrate that CRT results in significant improvement in clinical parameters, and considerable reductions in hospital admissions, and costs in patients with CCF.     

Long term outcome after balloon angioplasty and stenting of subclavian artery obstruction: a single centre experience

INTRODUCTION: Percutaneous transluminal angioplasty is an accepted and successful treatment strategy in obstructive disease of the subclavian artery. The purpose of this study was to evaluate the technical and clinical long-term outcome following endovascular therapy. PATIENTS AND METHODS: We retrospectively analyzed 99 patients (mean age of 65 +/- 10 years) with 100 interventions of the subclavian arteries and the brachiocephalic trunk with different aetiologies [atherosclerosis (90%); Takayasu's arteritis (5%); thromboembolism (2%); external compression (1%); iatrogenic dissection (1%) and occlusion after graft implantation in type B dissection (1%)]. RESULTS: Primary success rate was 97% (100% for stenoses and 90% for total occlusions). Treatment modalities included balloon angioplasty (PTA) alone (16%), stent implantation (78%), rotational thrombectomy (2%) and atherectomy (1%). The primary 1-year patency rate of the whole study cohort was 87% being not significantly lower after PTA (75%) compared to stent assisted angioplasty (89%). After thrombectomy and atherectomy no relevant restenosis were found. Multivariable analysis of 1-year restenosis-free survival revealed younger age (p = 0.03) and stenting (p = 0.04) as independent predictor. The blood pressure difference between both limbs at baseline was 42 +/- 24 mmHg and dropped to 10 +/- 14 mmHg after the intervention and 15 +/- 20 mmHg after 12 months, respectively (p = 0.01). CONCLUSIONS: Endovascular therapy of subclavian artery obstructions of various aetiologies offers good acute success rates even in total occlusions. Long-term patency rate is in favour of stent placement.     

Emergency coronary artery bypass surgery after intracoronary thrombolysis for evolving myocardial infarction.

Sixteen patients underwent emergency coronary artery bypass surgery immediately after intracoronary streptokinase infusion for acute evolving myocardial infarction. Of these, 11 patients had 70% residual stenosis in the recanalised vessel, and in five thrombolysis was unsuccessful. There were no hospital deaths. All the patients sustained myocardial necrosis, the peak activity of creatine phosphokinase correlating with the time to reperfusion. Chest tube drainage (mean 960 ml) was significantly higher than for control patients but did not correlate with the total dosage of streptokinase. No patients had further myocardial infarction or developed recurrent angina. Selected patients may benefit from coronary bypass surgery after intracoronary streptokinase infusion. If necessary this may be performed immediately with low mortality and morbidity.     

Acute myocardial infarction and cardiac arrest due to coronary artery perforation after mitral valve surgery: successful treatment with a covered stent

We present a case of a gentleman who presented with acute myocardial infarction and cardiac arrest 6 days after undergoing mitral valve replacement surgery. Immediate coronary angiography revealed perforation of the left circumflex artery which was successfully treated with a covered stent. This report details the successful percutaneous treatment of an exceedingly rare complication of mitral valve surgery.     

冠状动脉搭桥围术期急性心肌梗死紧急再搭桥

目的：回顾性分析冠状动脉搭桥围术期急性心肌梗死急诊再搭桥的临床经验。方法：在510例冠状动脉搭桥患中，5例患在术后4h内因急性心肌梗死需急诊再搭桥，发生率0．98％。5例患中，男女比例为4：1，年龄56－77岁（平均63．6岁），均为冠状动脉三支血管病变（3例伴左主干病变），手术中搭桥3－5支（人均搭桥3．6支），左乳内动脉桥5根，其余为大隐静脉桥。2例在关胸后20min，3例在回重症监护病房后2－4h出现急性心肌缺血表现（明显心电图ST－T变化），伴室颤2例，5例血液动力学均不稳定，药物处理难以稳定血液动力学。全部患均立即送手术室（2例仍在手术室），急诊再次开胸。探查发现，2例患静脉桥（分别搭桥到回旋支第二钝缘支和右冠状动脉后降支）内急性血栓形成；另3例所有静脉桥良好，但左室前壁收缩运动明显减弱，结合心电图变化，诊断为左乳内动脉灌注不良。重新建立体外循环，清除桥内血栓重新搭桥2例（1例在非体外循环心脏跳动下进行）；另取一段静脉搭桥到左乳内动脉－左前降支吻合口远端的左前降支3例。结果：5例患顺利度过手术，均置入主动脉内球囊反搏，支持22－25h（平均42h）。手术后呼吸机支持4h－18d（平均7．3d）合并消化道出血4例，肾功能不全2例，肺部感染2例，切口感染1例。手术后住院时间12－35d，平均21d。全组均痊愈出院。结论：冠状动脉搭桥围术期急性心肌梗死应重在预防。如怀疑桥有问题，急诊再搭桥是良好选择，但手术后并发症发生率明显增加。     

Emergency coronary artery stenting for coronary dissection complicating diagnostic cardiac catheterisation.

Dissection of a coronary artery is a recognised and significant complication of diagnostic coronary angiography that often requires emergency coronary artery bypass grafting. A coronary stent was used to treat this complication. This technique has potential advantages in terms of speed of reperfusion and availability in centres performing diagnostic angiography without surgical cover on site.     

Syncope: a symptom of coronary artery spasm after cardiac transplantation.

Two cases of coronary spasm in cardiac transplant recipients in which the presenting symptom was syncope without chest pain are reported. Diagnosing coronary spasm in transplant patients appears to be important because, based upon the few cases in the literature, prognosis is very poor. Coronary spasm may be related to accelerated atherosclerosis occurring in the transplanted heart.     

Emergency coronary artery bypass surgery after intracoronary thrombolysis for evolving myocardial infarction

Sixteen patients underwent emergency coronary artery bypass surgery immediately after intracoronary streptokinase infusion for acute evolving myocardial infarction. Of these, 11 patients had 70% residual stenosis in the recanalised vessel, and in five thrombolysis was unsuccessful. There were no hospital deaths. All the patients sustained myocardial necrosis, the peak activity of creatine phosphokinase correlating with the time to reperfusion. Chest tube drainage (mean 960 ml) was significantly higher than for control patients but did not correlate with the total dosage of streptokinase. No patients had further myocardial infarction or developed recurrent angina. Selected patients may benefit from coronary bypass surgery after intracoronary streptokinase infusion. If necessary this may be performed immediately with low mortality and morbidity.