Journal of cardiothoracic and vascular anesthesia
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J. Cardiothorac. Vasc. Anesth. · Dec 2006
Long-term outcome of patients with perioperative myocardial infarction as diagnosed by troponin I after routine surgical coronary artery revascularization.
Diagnosis of perioperative myocardial infarction (P-MI) after coronary artery bypass graft (CABG) surgery traditionally relied on a combination of electrocardiographic and enzyme assay changes. Patients with Q-wave P-MIs who survive to hospital discharge have a poorer long-term prognosis. Troponin assays are more sensitive and specific for detecting minor P-MI, with an increased incidence of P-MI being reported. This study investigated if P-MI after CABG surgery, as defined by troponin-I isozyme (cTn-I), correlated with long-term outcome. ⋯ It was shown that P-MI as defined by cTn-I is associated with an increased long-term incidence of adverse cardiovascular events. An elevated peak cTn-I level (>or=15 microg/L) identified patients at increased risk but did not have a powerful positive predictive value for either cardiovascular (48%) or vascular (26%) complications. However, a peak cTn-I <15 microg/L was a negative predictor of adverse vascular outcome (95%). This may have implications for postoperative patient follow-up.
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J. Cardiothorac. Vasc. Anesth. · Dec 2006
Implication of the anatomy of the pericardial reflection on positioning of central venous catheters.
Central venous catheterization is associated with a significant incidence of complications (5%-20%). The incidence of perforation is approximately 0.25% to 0.4%. To prevent cardiac tamponade associated with a high risk of death, Food and Drug Administration guidelines state that the tip of a central venous catheter (CVC) should not be placed in, or allowed to migrate into, the heart. Therefore, in order to prevent cardiac tamponade, a catheter should be placed above the pericardial reflection. Thus, the intrapericardial length of the superior vena cava (SVC) was studied. Neither the pericardial reflection nor the exact entrance to the right atrium (RA) can be identified by chest x-ray. The goal of this study was to evaluate the variability of the intrapericardial section in relation to the SVC. ⋯ Catheters ending below the pericardial reflection, hence positioned in the caudal third of the SVC, are likely to run along the long axis of the vein and the risk for perforation is minimized. Therefore, the authors recommend placing all catheters below the pericardial reflection. According to the present data, CVCs placed approximately 30 mm above the RA border, thus complying with the Food and Drug Administration guidelines, still may have their tips positioned below the pericardial reflection. In this position, pericardial tamponade still may occur. Perforation above the pericardial reflection will result in a hemo- or hydrothorax/mediastinum. A bedside method to determine the position of the CVC with respect to the pericardial reflection (eg, electrocardiographic guidance) should be used.