European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery
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Eur J Cardiothorac Surg · Jun 2010
Review Meta AnalysisLessons from aprotinin: is the routine use and inconsistent dosing of tranexamic acid prudent? Meta-analysis of randomised and large matched observational studies.
In view of the safety concerns that led to the withdrawal of aprotinin, should antifibrinolytics be used indiscriminately in cardiac surgery? This meta-analysis examines the efficacy and safety profile of tranexamic acid, and in comparison to aprotinin. We identified randomised trials and large observational studies investigating the use tranexamic acid from January 1995 to January 2009 using Pubmed/Cochrane search engine and included them in a two-tier meta-analysis. There were 25 randomised trials and four matched studies with a total of 5411 and 5977 patients, respectively, reporting tranexamic acid use in varying dosages. ⋯ Compared to aprotinin, tranexamic acid has less effective blood-conserving effect and mortality risk. Given the potential to increase neurological complications, the current trend towards indiscriminate use of tranexamic acid for all cardiac patients needs to be re-evaluated. Further studies are needed to clarify the neurological risk, appropriate indications and dosing of tranexamic acid.
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Eur J Cardiothorac Surg · Jun 2010
Clinical TrialModified thromboelastography evaluation of platelet dysfunction in patients undergoing coronary artery surgery.
Anti-platelet therapy is associated with increased perioperative bleeding. Although current guidelines call for its caessation 5-10 days prior to cardiac surgery, this could constitute an increased risk of preoperative myocardial infarction. The optimal safe period from discontinuation of anti-platelet therapy to surgery is as yet unknown for the individual patient. We investigated whether preoperative thromboelastography (TEG) with platelet mapping could predict bleeding tendency in patients (on recent anti-platelet therapy) undergoing coronary artery bypass grafting (CABG). ⋯ TEG with platelet mapping is able to predict excessive postoperative blood loss among patients who underwent CABG and recent anti-platelet therapy. The prevalence of non-responsiveness to anti-platelet therapy, including clopidogrel, is higher in patients undergoing coronary artery bypass grafting than in the general population. In this study, aspirin-induced platelet dysfunction did not influence postoperative blood loss.
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Eur J Cardiothorac Surg · Jun 2010
Correction of leaflet prolapse extends the spectrum of patients suitable for valve-sparing aortic root replacement.
Preservation of the native aortic valve in patients requiring aortic root replacement avoids the need for lifelong anticoagulation and potentially offers greater durability than a bio-prosthetic valve. Such techniques have generally been applied to patients with early grades of aortic regurgitation (AR) and less severe aortic root dilatation where leaflets have been minimally stretched. We reviewed our experience with these techniques and in particular the durability of the addition of leaflet prolapse correction in patients with more advanced aortic root pathology compared to those with non-prolapsing leaflets. ⋯ Patients with large aortic root aneurysms and advanced AR often have stretched leaflets that will prolapse and lead to early failure if only root geometry is corrected. With the addition of leaflet prolapse correction, we have shown equivalent durability to those without stretched leaflets. This has allowed valve preservation in a sizable subgroup who would otherwise have received prosthetic valves. Greater patient numbers and longer follow-up are needed to fully validate this approach.
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Eur J Cardiothorac Surg · Jun 2010
Congenital heart disease: interrelation between German diagnosis-related groups system and Aristotle complexity score.
The Disease-Related Groups (DRGs) system postulates that inpatient stays with similar levels of clinical complexity are expected to consume similar amounts of resources. This, applied to surgery of congenital heart disease, suggests that the higher the complexity of procedures as estimated by the Aristotle complexity score, the higher hospital reimbursement should be. This study analyses how much case-mix index (CMI) generated by German DRG 2009 version correlates with Aristotle score. ⋯ ACC score correlates almost perfectly with corresponding cost-weights (CMI) generated by the German DRG 2009. It could therefore be used as the basis for hospital reimbursement to compensate in conformity with procedures' complexity. Extrapolated CMI in this series would be 9.264. Modulation of reimbursement according to surgical performance could be established and thus 'reward' quality in congenital heart surgery.
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Eur J Cardiothorac Surg · Jun 2010
Clinical outcome of resected solid-type small-sized c-stage IA non-small cell lung cancer.
The chances of pulmonary resection for small-sized lung cancer have increased because of the development of thin-slice computed tomography (CT). Though sublobar resection could be indicated for ground glass opacity (GGO)-dominant adenocarcinoma with low-grade behaviour, the malignant potential of solid-type, small-sized lung cancer has not been sufficiently assessed. We aimed to address the clinical outcomes of resected solid-type c-stage IA non-small cell lung cancer (NSCLC) smaller than 2 cm. ⋯ A proportion of solid-type NSCLC has malignant potential, even for tumours smaller than 2 cm. Periodic intrathoracic evaluation is required following complete resection.