Off pump coronary artery bypass (OPCAB) in critical left mainstem stenosis—Our experience

Background Beating heart surgery has now become the commonest technique of doing Coronary Artery Bypass Graft Surgery (CABG) in our country. It is being used even in such high risk situations like diffuse coronary disease and Critical Left Main stem Stenosis (LMCS) with good results. The aim of this study is to retrospectively review our results in Off-Pump Coronary Artery Bypass Surgery (OPCAB) in patients with critical left main stem stenosis. Methods This study is a retrospective analysis of the data of patients who underwent primary coronary artery bypass surgery. During the period from April 2003 to September 2005 a total of 64 patients underwent OPCAB procedure for critical LMCS. During the same period 10 patients underwent CABG on Cardio Pulmonary Bypass (CPB). The age range was 36–77yrs. The sex distribution was M: F 53∶10. Ten patients were done as emergency. 2 of them were on Intra Aortic Balloon Pump (IABP) support preoperatively. 10 patients were high risk with a Euro score of ≥5. Results Left Internal Mammary Artery (LIMA) was used in 78% of cases. Average grafts per patient was 2.96. The median ventilation time was 5.91 hrs. New IABP insertion in postoperative period was required in 1 patient. One patient was reexplored for bleeding. There was one perioperative myocardial infarction. 57% of patients did not need any blood transfusion. There was no conversion to CPB. There was no operative mortality. Inotropes were used in ten cases. Conclusions OPCAB is a safe method of revascularization in patients with critical LMCS. Preoperative IABP is useful in patients with cardiogenic shock. However, there is a place for CPB in patients needing additional procedures like Mitral Valve repair (MV repair) or Dor's procedure or when the vessels are very diffusely diseased. Those patients who are unstable despite IABP support may be managed by Beating heart On Pump (BHOP) technique.     

Indices of surgical site infection risk and prediction of other adverse outcomes during hospitalization.

OBJECTIVE: To assess which adverse postsurgical outcomes are best predicted by the Study on the Efficacy of Nosocomial Infection Control (SENIC) index and the National Nosocomial Infection Surveillance system (NNIS) index. DESIGN: Prospective cohort study. SETTING: The service of general surgery at a tertiary care hospital. PATIENTS: A consecutive series of patients hospitalized for more than 1 day (n=2,989). RESULTS: The outcome best predicted by the SENIC and NNIS indices was assessed by estimating the area under the receiver operating characteristic (ROC) curve. The areas under the ROC curves for nosocomial infection and in-hospital death were higher for the NNIS index than they were for the SENIC index (P<.05). The NNIS index predicted in-hospital death better than it predicted surgical site infection (area under the ROC curve+/-SE, 0.836+/-0.022 vs 0.689+/-0.017; P=.001). CONCLUSIONS: The NNIS index is superior to the SENIC index for all adverse postsurgical outcomes. Its ability to predict in-hospital mortality is clearly better than its ability to predict surgical site infection.     

Massive intratubular hemorrhage with herniations into renal veins: report of a case

A 24-year-old man had unilateral gross hematuria that required nephrectomy. Pathological examination revealed massive intratubular hemorrhage and frequent deposition of an amorphous and homogeneous material positive for periodic acid, Schiff stain in the corticomedullary junction. This substance had the characteristics of Tamm-Horsfall protein and frequently herniated into the lumen of thin-walled veins of arcuate size. There was no apparent cause for the bleeding. To the best of our knowledge this is the third reported case with these peculiar findings and no apparent cause. We discuss some hypotheses as to the etiopathogenesis of this rare and intriguing condition.