The Annals of thoracic surgery
-
Given substantial advances in venovenous extracorporeal membrane oxygenation (ECMO) technology, long-term support is increasingly feasible. Although the benefits of short-term ECMO as a bridge to recovery in acute respiratory distress syndrome (ARDS) are well described, the utility and outcomes of long-term support remain unclear. ⋯ Previously, long-term ECMO support was thought to be associated with unfavorable outcomes. This study, however, may provide support for the efficacy of ECMO support even for 3 weeks or more as a bridge to recovery or transplantation.
-
Accurate risk assessment in patients presenting for aortic valve replacement (AVR) after prior coronary artery bypass grafting (CABG) is essential for appropriate selection of surgical versus percutaneous therapy. ⋯ In patients presenting for AVR after prior CABG, the STS online risk calculator overestimates risk for all but the highest risk patients. Using a cohort-specific recalibration equation, a substantial proportion of patients would be downgraded to lower risk categories. The cohort-specific recalibration correlates well with the existing generic quarterly STS recalibration. The findings of this study support recommendations for periodic recalibration of the online risk calculator in order to facilitate clinical decision making in real time.
-
The bilateral transverse thoracosternotomy clamshell incision provides excellent exposure to the mediastinal structures in double lung transplantation. The use of a modified transverse sternotomy and a figure of 8 configuration with one monofilament metal wire, along with two longitudinal wires across the sternal division, results in greater stability and equally distributed oblique tension. Our described technique was more cost effective and resulted in no incidence of dehiscence. We present our experience using a modified transverse sternotomy and reinforced sternal closure method.
-
Randomized Controlled Trial Multicenter Study
Intraoperative High-Dose Dexamethasone in Cardiac Surgery and the Risk of Rethoracotomy.
Cardiac surgery with the use of cardiopulmonary bypass is associated with a systemic inflammatory response. Intraoperative corticosteroids are administered to attenuate this inflammatory response. The recent Dexamethasone for Cardiac Surgery (DECS) trial could not demonstrate a beneficial effect of dexamethasone on major adverse events in cardiac surgical patients. Previous studies suggest that corticosteroids may affect postoperative coagulation and blood loss, and therefore could influence the risk of surgical reinterventions. We investigated the effects of prophylactic intraoperative dexamethasone treatment on the rate of rethoracotomy after cardiac surgery. ⋯ Intraoperative high-dose dexamethasone administration in cardiac surgery was associated with an increased rethoracotomy risk.
-
Postthoracotomy pain is quite intense. Epidural analgesia (EPI) has long been the gold standard but is often associated with hypotension and urinary retention. The recent availability of liposomal bupivacaine formulation (Exparel) stimulated us to use it for multilevel intercostal nerve blocks (IB) injected during open thoracotomy. ⋯ It appears that intraoperative IB with bupivacaine liposome at 6 levels during thoracotomy provided significantly better pain control in postoperative days 1 and 3, compared to EPI in this retrospective study. This technique is simple, safe, and reproducible. It does not require epidural space invasion, infusion pumps, or another service to comanage the postoperative pain therapy.