Patency of the false lumen is a strong independent prognostic factor for type B aortic dissection. Location of the most dilated aortic segment at the distal arch is a significant risk factor in the patients with a patent false lumen.
Low-frequency ventilation during cardiopulmonary bypass in a pig experimental model reduces tissue metabolic and histologic damage in the lungs and is associated with improved postoperative gas exchange.
Cardiopulmonary bypass (CPB) has been implicated as a cause of acute lung injury (ALI) in cardiac surgical patients. We used a bronchoscopic microsampling (BMS) probe to examine alveolar biochemical constituents and evaluated the effect of sivelestat sodium hydrate, a novel synthesized polymorphonuclear (PMN) neutrophil elastase inhibitor, on ALI induced by CPB. Twelve patients undergoing aortic valve replacement were treated with either sivelestat 0.2 mg/kg/h (sivelestat group, n=6) or 0.9% saline (control group, n=6) from the start of surgery. Samples were collected by the BMS probe at three time points: after tracheal intubation, 1 h after CPB introduction, and 3 h after CPB termination. Pulmonary function was assessed perioperatively. There were no differences in baseline characteristics. The concentration of PMN elastase was significantly suppressed in the sivelestat group, compared with the control group (P=0.001). The sivelestat group also had lower levels of interleukin-6 and interleukin-8. Alveolar-arterial oxygen difference markedly increased, and a worsening of the PaO(2)/FiO(2) ratio indicated severe impairment after CPB. However, sivelestat attenuated the pattern of physiological deterioration of gas exchange. Sivelestat may attenuate neutrophil elastase or proinflammatory cytokines, and improve pulmonary dysfunction in patients undergoing CPB.
Although the long-term benefits of conventional coronary artery bypass grafting (CABG) are obvious, postoperative morbidity and mortality and the length of recovery associated with cardiopulmonary bypass are the main concerns of cardiac surgeons and cardiologists. The aim of this study was to demonstrate the effectiveness and advantage of the off-pump CABG for patients with concomitant malignant disorders requiring myocardial revascularization. From March 1997 to February 1999, 51 patients underwent off-pump CABG. Of these, there were 9 patients who had concomitant malignant disease requiring noncardiac surgery: gastric cancer (4), urinary bladder cancer (2), cholangioma (1), lung cancer (1) and colon cancer (1). Off-pump CABG was performed through a sternotomy, left thoracotomy or subxiphoid incision. Five patients received single grafting and 4 received double. The mean operative time for the off-pump CABG was 167 min. The total amount of bleeding during the off-pump CABG was 450-890 ml. Simultaneous noncardiac operations were carried out in 5 patients. The other 4 patients underwent subsequent operations for the malignancy uneventfully. In contrast, of the 4 patients with concomitant malignant disorders who underwent standard CABG during the period before the use of off-pump CABG, 2 died without undergoing the subsequent noncardiac operation. Off-pump CABG is quite efficient and is of great advantage in patients with malignancy who require myocardial revascularization in addition to noncardiac surgery for the cancer.
: Meta-analysis of Level A and B evidence provided the basis for the following consensus statements in patients undergoing surgical myocardial revascularization: (1) OPCAB should be considered a safe alternative to CCAB with respect to risk of mortality [Class I, Level A]; (2) With appropriate use of modern stabilizers, heart positioning devices, and adequate surgeon experience, similar completeness of revascularization and graft patency can be achieved [Class IIa, Level A]; (3) OPCAB is recommended to reduce perioperative morbidity [Class I, Level A]; (4) OPCAB may be recommended to minimize midterm cognitive dysfunction [Class IIa, Level A]; (5) OPCAB should be considered as an equivalent alternative to CCAB in regard to quality of life [Class I, Level A]; (6) OPCAB is recommended to reduce the duration of ventilation, ICU and hospital stay, and resource utilization [Class I, Level A]; (7) OPCAB should be considered in high-risk patients to reduce perioperative mortality, morbidity, and resource utilization [Class IIa, Level B].
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