... Cardiothoracic Care Centre, St Vincent's Hospital, Melbourne, Australia.... more ... Cardiothoracic Care Centre, St Vincent's Hospital, Melbourne, Australia. Department of Surgery, Monash University, Victoria, Australia. Department ... Cardiothoracic Surgery Unit, Monash Medical Centre, Victoria, Australia. Department ...
was significantly reduced in patients who underwent OPCAB compared to CABG (9 pts (15.8%) vs. 76 ... more was significantly reduced in patients who underwent OPCAB compared to CABG (9 pts (15.8%) vs. 76 pts (28.9%), p < 0.05). OPCAB (n = 57) CABG (n = 263) Age (years) 49.6 51.7 Male sex, n (%) 34 (59.6%) 190 (72.2%) Mortality 1 (1.7%) 5 (1.9%) Stroke 0 (0) 1 (0.3%) AMI, n (%) 0 (0) 14 (5.3%) New onset renal failure, n (%) 2 (3.5%) 21 (8.0%) Prolonged ventilation, n (%) 8 (14%) 45 (17.1%) Deep sternal wound infection, n (%) 0 (0) 2 (0.7%) Reoperation, n (%) 3 (5.2%) 17 (6.5%) Conclusions: OPCAB reduced postoperative morbidity in ATSI patients. Short-term mortality was comparable between OPCAB and CABG groups. These findings suggest that OPCAB may be a better technique for surgical revascularisation in this group of patients.
Background: Gastrointestinal (GI) complications after cardiac surgery are uncommon, but are assoc... more Background: Gastrointestinal (GI) complications after cardiac surgery are uncommon, but are associated with high morbidity and mortality as well as significant hospital resource utilization. Methods: We analysed a prospectively collected database containing all adult cardiac surgery procedures performed from July 2001 to March 2011 at Monash Medical Centre and Jessie McPherson Private Hospital. Patients with post-operative GI complications were compared to patients without GI complications who were operated in the same period. Results: The incidence of GI complications was 1.1% (61 out of 5382 patients) with an overall 30-day mortality of 33% (versus 3% in the non-GI complication group). The most common complications were GI bleeding, gastroenteritis and bowel ischaemia. Patients who had GI complications were significantly older, had higher incidence of renal impairment, chronic lung disease and anticoagulation therapy and were more likely to be in cardiogenic shock. Emergency procedures, combined coronary artery bypass grafting and valve surgery and aortic dissection cases were more common in the GI complication group. The GI complication group also had higher incidence of return to theatre, renal failure, stroke, septicaemia and multi-organ failure. Conclusions: GI complications after cardiac surgery remain an uncommon but dreadful complication associated with high mortality. Our findings should prompt a high degree of clinical vigilance in order to make an early diagnosis especially in high risk patients. Further studies aiming to identify independent predictors for GI complications after cardiac surgery are warranted. study was to investigate the incidence, pattern and outcomes of GI complications after cardiac surgery in an Australian institution and compare these results to the findings of prior studies. Methods We performed a retrospective review of a prospectively collected database containing all adult cardiac procedures performed from 1 July 2001 to 31 March 2011 at Monash Medical Centre and Jessie McPherson Private Hospital, both tertiary referral centres in metropolitan Melbourne, Australia. Data were prospectively collected as part of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database project. The database records detailed patient demographics, preoperative risk factors, operative technique, post-operative hospital course and CARDIOTHORACIC
Between 1961 and 1991, 23 patients (eight men and 15 women, with a mean age of 50 (range 25-72) y... more Between 1961 and 1991, 23 patients (eight men and 15 women, with a mean age of 50 (range 25-72) years) with cardiac myxomas were managed at the Alfred Hospital, Prahran, victoria, Australia. Symptoms of mitral valve obstruction were present in 13 patients and of systemic embolism in nine. In the patients, 21 myxomas were confined to the left atrium. In the other two patients, one myxoma was confined to the right atrium and the other was a dumb-bell-shaped biatrial myxoma. Most tumours were diagnosed with echocardiography. Removal was achieved via a median sternotomy and by entering the involved chamber. Those myxomas presenting with systemic embolism were always soft and friable, whereas those with obstructive symptoms were large and of variable consistency. There was one operative death early in the series. The 22 surviving patients have been assessed as functional class 1 of the New York Heart Association at follow-up. ranging from 2 months to 23 years (mean 9 years). There were n...
Clinical and Experimental Pharmacology and Physiology, 2021
Acute kidney injury (AKI) is a common and serious post‐operative complication of cardiac surgery.... more Acute kidney injury (AKI) is a common and serious post‐operative complication of cardiac surgery. The value of a predictive biomarker is determined not only by its predictive efficacy, but also by how early this prediction can be made. For a biomarker of cardiac surgery‐associated AKI, this is ideally during the intra‐operative period. Therefore, in 82 adult patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB), we prospectively compared the predictive efficacy of various blood and urinary biomarkers with that of continuous measurement of urinary oxygen tension (UPO2) at pre‐determined intra‐ and post‐operative time‐points. None of the blood or urine biomarkers we studied showed predictive efficacy for post‐operative AKI when measured intra‐operatively. When treated as a binary variable (≤ or > median for the whole cohort), the earliest excess risk of AKI was predicted by an increase in urinary neutrophil gelatinase‐associated lipocalin (NGAL) at 3 h after en...
rax with upper abdomen. After general anaesthesia had been induced with double-lumen tracheal int... more rax with upper abdomen. After general anaesthesia had been induced with double-lumen tracheal intubation, the patient was positioned in right lateral decubitus. Mini-thoracotomy performed over seventh rib extending from anterior costal margin for 4 cm. The myotomy was carried out proximally to the level of the left inferior pulmonary vein and distally for approximately 1.5 cm on the anterolateral portion of the gastric cardia. Chest was closed with single drain chest xray was done in the immediate postoperative period, and then the patient was orally allowed. Mean operative time was 25 minutes. Operative data obtained included duration of surgery, intraoperative complications, and postoperative complications, including perforation, atelectasis, pneumonia, and length of hospital stay. Results: Mortality was nil. Morbidity was four (1.93%), all in the form of atelectasis. There were no leaks. Of 207 patients, 197 had no symptoms after a follow-up of 12 months, whereas eight patients had reflux and seven patients had persistent dysphagia with megaoesophagus. They subsequently underwent oesophagectomy with stomach pull-up. Mean operative time was 25 minutes and mean length of hospital stay was 3 days. Conclusions: Transthoracic Heller myotomy via left anterior mini-thoracotomy for achalasia is a safe and effective procedure giving satisfactory results with minimum operative time, hospital stay, and morbidity and with no mortality.
Introduction: South Africa continues to be burdened by human immunodeficiency virus [HIV] and tub... more Introduction: South Africa continues to be burdened by human immunodeficiency virus [HIV] and tuberculosis [TB]. In Cape Town, the epidemic of HIV-TB co-infection is as high as 70%. Granulomatous interstitial nephritis [GIN] has increased in frequency on renal biopsy. This study aimed to determine GIN prevalence and causes in HIV positive patients as well as renal outcomes, patient survival and associated factors. Methods: This observational cohort study reviewed HIV positive renal biopsies for GIN from 2005-2012. Causes of GIN (medications, TB, fungal and other), and baseline characteristics were analysed. A comparison of baseline data, renal function and survival was made between GIN and non-GIN cohorts. Results: There were 45/316 biopsies demonstrating GIN. TB was the likely cause of GIN in 27 [60%] and 9 [20%] were due to a drug. Low eGFR was statistically significant for mortality in both GIN [p=0.045] and non-GN cohorts [p<0.000]. In the GIN group there were 12 (26.7%) deaths. Mortality for all patients was greatest in the first 6 months [p= 0.057]. TB co-infection in both cohorts was associated with a higher mortality. The final creatinine at 12 months was worse in the GIN group however not significant [p=0.522]. Conclusions: GIN is common in HIV positive renal biopsies in Cape Town. TB-GIN was the commonest cause and associated with a high early mortality. GIN should be considered in HIV positive patients with acute kidney injury, its presence conveys a survival benefit. There is a need for improved diagnostic accuracy and treatment strategies of TB-GIN.
Predominantly based on studies from high-income countries, reduced estimated glomerular filtratio... more Predominantly based on studies from high-income countries, reduced estimated glomerular filtration rate (eGFR) has been associated with increased risk of infections and infection-related hospitalizations (IRHs). We here explore in-hospital outcomes of IRHs in patients with different kidney function. A total of 6,283 adults, not on renal replacement therapy, with a discharge diagnosis of infection, and with an eGFR 1–12 months before index hospitalization, were included from four hospitals in China. We compared in-hospital outcomes (death, intensive care unit (ICU) admission, length of hospital stay (LOHS) and medical expenses), between patients with and without chronic kidney disease (CKD, defined as eGFR ≤ 60 ml/min per 1.73 m2 of body surface area) by mixed-effects logistic regression model or generalized linear model. The odds for in-hospital mortality (adjusted odds ratios (OR) = 1.41; 95% CI 1.02–1.96) and ICU admission (OR = 2.18; 95% CI 1.64–2.91) were higher among patients w...
An increasing proportion of patients present for concomitant aortic valve replacement (AVR) and c... more An increasing proportion of patients present for concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) with left ventricular (LV) dysfunction. The aim of this study was to evaluate the early outcomes and late survival of patients with different degrees of LV function undergoing concomitant AVR and CABG. Between June 2001 and December 2009, patients undergoing concomitant AVR-CABG were identified from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program. Demographic, operative data and post-operative outcomes were compared between patients with normal (> 60%), moderately impaired (30- -60%), and severely impaired (< 30%) estimated LV ejection fraction (LVEF). Independent risk factors for short- and long-term mortality were identified using binary logistic and Cox regression, respectively. AVR-CABG was performed in 2,563 patients with a mean follow up of 36 months (range 0-106). 144 (5.6%) had se...
Journal of cardiovascular medicine (Hagerstown, Md.), 2014
Postoperative atrial fibrillation (POAF) is a known complication of cardiac surgery. There is a p... more Postoperative atrial fibrillation (POAF) is a known complication of cardiac surgery. There is a paucity of data on the effects of POAF on short-term and long-term outcomes after concomitant aortic valve replacement and coronary artery bypass grafting (AVR-CABG ). We retrospectively reviewed data on patients without preexisting arrhythmia who underwent isolated first-time AVR-CABG between June 2001 and December 2009 using the Australasian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program. Preoperative characteristics, early postoperative outcomes and late survival were compared between patients who developed POAF and those who did not. Propensity score matching was performed to account for the differences between the two groups. Isolated AVR-CABG surgery was performed in 2028 patients without preexisting arrhythmias at 18 Australian institutions, of whom 894 (44.1%) developed POAF. POAF patients were generally older (mean age, 75 vs. 73 years, P < ...
The Journal of Thoracic and Cardiovascular Surgery, 2013
Objective: No previous studies have specifically addressed the effect of training on outcomes aft... more Objective: No previous studies have specifically addressed the effect of training on outcomes after concomitant aortic valve replacement and coronary artery bypass grafting. This study evaluated the early and late outcomes after concomitant aortic valve replacement and coronary artery bypass grafting performed by surgeons in training. Methods: A retrospective analysis of data collected prospectively by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database between June 2001 and December 2009 was performed. Concomitant aortic valve replacement and coronary artery bypass grafting was performed in 2540 patients; of these procedures, 290 (11.4%) were by trainees. Patient demographics, intraoperative characteristics, and early morbidity were compared between trainee and staff cases using chi-square analysis and t tests. Multivariate analyses were used to determine the independent association of training status with 30-day and late mortality. Results: Compared with staff cases, trainee cases were younger (mean age, 73.0 vs 74.2 years; P ¼ .025) and less likely to present with triple vessel disease (27.9% vs 38.3%, P ¼ .001) or previous cardiac surgery (6.3% vs 2.8%, P ¼ .016). Trainee cases had longer mean perfusion (160.4 vs 144.6 minutes, P<.001) and crossclamp (125.2 vs 114.6 minutes, P <.001) times. The incidence of early complications was similar between the 2 groups. On multivariate analysis, trainee status was not associated with an increased risk of 30-day mortality (2.4% vs 4.0%, P ¼ .348). Moreover, there was no significant difference in long-term outcomes, and 5-year survival was comparable in both groups (79.6% vs 77.4%, P ¼ .200). Conclusions: Concomitant aortic valve replacement and coronary artery bypass grafting can be safely and effectively performed by properly supervised trainees in the contemporary era. It is imperative to offer training opportunities to junior surgeons in this complex procedure to ensure quality patient outcomes in the future.
conception and design, data acquisition, analysis and interpretation of data, and drafting of the... more conception and design, data acquisition, analysis and interpretation of data, and drafting of the manuscript. Glenda Campbell: conception and design, development of prescribing alerts, testing and verification of the computer application, data acquisition, analysis and interpretation of data, and critical review of the manuscript. Amit X. Garg and Lisa Dolovich: conception and design, development of prescribing alerts, analysis and interpretation of data, and critical review of the manuscript. Jackie B. Stroud: conception and design; data acquisition; analysis and interpretation of data; critical review of the manuscript; coordination of the development, testing, and verification of the computer application. Ruth E. McCallum: critical revision and formatting of the manuscript and final approval of the manuscript. Alexandra Papaioannou: conception and design, development of prescribing alerts, data acquisition, analysis and interpretation of data, and critical review of the manuscript.
Background: There are limited data on the impact of smoking status on outcomes after isolated cor... more Background: There are limited data on the impact of smoking status on outcomes after isolated coronary artery bypass graft (CABG) surgery. Methods: Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program were retrospectively analyzed. Demographic and operative data were compared between patients who were non-smokers, previous smokers, and current smokers. The independent impact of smoking status on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively. Results: Isolated CABG surgery was performed in 21 534 patients; smoking status was recorded in 21 486 (99.8%). Of these, 7023 (32.6%) had no previous smoking history, 11 183 (59.1%) were previous smokers, and 3290 (15.2%) were current smokers. The 30-day mortality rate was 1.8% in non-smokers, 1.5% in previous smokers, and 1.5% in current smokers (p = NS). The incidence of peri-operative complications was generally similar in the three groups, but current smokers were at an increased risk of pneumonia (p < 0.001), and multisystem failure (p = 0.003). The mean follow-up period for this study was 37 months (range, 0-106 months). After adjusting for differences in patient variables, the incidence of late mortality was higher in previous smokers [hazard ratio (HR), 1.73; 95% confidence interval (CI), 1.47-2.05; p < 0.001] or current smokers (HR, 1.41; 95% CI, 1.26-1.59; p < 0.001) compared to non-smokers. Conclusion: Smoking status is not associated with early mortality after isolated CABG. It is, however, associated with an increased risk of pulmonary complications and reduced long-term survival.
Introduction: Pneumothorax caused by apical cysts is a common pathology in young, otherwise healt... more Introduction: Pneumothorax caused by apical cysts is a common pathology in young, otherwise healthy patients. Here we report a case of a young female who was referred to us with a large left spontaneous pneumothorax, refractory to chest drain management, in the setting of first trimester pregnancy. The first and third trimesters of pregnancy are the most dangerous times to administer general anaesthetic, due to the risk of teratogenicity in the former, and preterm labour in the latter, with administration after the 24th week is considered advantageous for foetal viability, in the event of induction of labour. Also, the effects of sclerotic agents such as talcum powder are unknown in pregnancy, with the best evidence available coming from rodents. This case highlights the difficulties in managing pregnant patients with serious conditions where a surgical option exists, and the continuous evaluation of risk vs benefit that must ensue. Methods: A previously fit and well 22 year old G1P0 23 week pregnant female was referred to our service following unsuccessful management of a large left tension pneumothorax with a 12 French intercostal catheter. Subsequent management with large bore chest tube and high suction remained unsuccessful after a further two weeks. Expert obstetric and anaesthetic opinion was sought, due to perceived risk of empyema and blockage of drain with resultant tension pneumothorax (as demonstrated on the ward with a kinked tube on two occasions). Results: After careful consideration, our patient was taken to theatre at 25 + 5/40 for left VATS bullectomy + pleural abrasion. The operation was uneventful, and she was discharged five days later. A healthy baby was born at full term, with the only remaining gestational complication being a case of pyelonephritis requiring antibiotics. Discussion: We present this case together with a series of photographs taken intraoperatively, and a review of the literature regarding treatment of pneumothorax and general anaesthetic in pregnancy. In these cases, risk assessment is vital to ensure the best likelihood of a good outcome for two patients, sometimes with competing demands.
sufficiently to enable circulatory arrest, therefore permitting repair of the arch pathology. How... more sufficiently to enable circulatory arrest, therefore permitting repair of the arch pathology. However, no standardised classification of hypothermia exists for arch surgery, with terms such as 'profound', 'deep', 'moderate', and 'mild' hypothermia used without distinction between institutions. Methods: An international panel of experts, representing high-volume aortic centres from Australia, Asia, Europe, and North America, collaborated and reached the following consensus regarding 'profound', 'deep', 'moderate', and 'mild' hypothermia, based on existing EEG and metabolic studies of brain function. Discrepancies in opinions were resolved by online voting system. Consensus was reached when greater than 50% of the panel concurred on a response. Results: All 14 leading arch surgeons included in the panel agreed upon the classification: profound hypothermia, 14 8C; deep hypothermia, 14.1-20 8C; moderate hypothermia, 20.1-28 8C; and mild hypothermia, 28.1-34 8C. At these temperature ranges, profound, deep, moderate, and mild hypothermia is expected to afford 30-40, 20-30, 10-20, and 10 minutes of 'safe' circulatory arrest duration, respectively (Figure 1). Based on the existing evidence, it is also recommended that arrest temperature be measured at the nasopharynx. Conclusion: A concerted effort is required to standardise much of the nomenclature of aortic arch surgery. Endeavours such as this will facilitate more consistent and valid comparisons between surgical approaches and institutions.
... Cardiothoracic Care Centre, St Vincent&amp;amp;amp;#x27;s Hospital, Melbourne, Australia.... more ... Cardiothoracic Care Centre, St Vincent&amp;amp;amp;#x27;s Hospital, Melbourne, Australia. Department of Surgery, Monash University, Victoria, Australia. Department ... Cardiothoracic Surgery Unit, Monash Medical Centre, Victoria, Australia. Department ...
was significantly reduced in patients who underwent OPCAB compared to CABG (9 pts (15.8%) vs. 76 ... more was significantly reduced in patients who underwent OPCAB compared to CABG (9 pts (15.8%) vs. 76 pts (28.9%), p < 0.05). OPCAB (n = 57) CABG (n = 263) Age (years) 49.6 51.7 Male sex, n (%) 34 (59.6%) 190 (72.2%) Mortality 1 (1.7%) 5 (1.9%) Stroke 0 (0) 1 (0.3%) AMI, n (%) 0 (0) 14 (5.3%) New onset renal failure, n (%) 2 (3.5%) 21 (8.0%) Prolonged ventilation, n (%) 8 (14%) 45 (17.1%) Deep sternal wound infection, n (%) 0 (0) 2 (0.7%) Reoperation, n (%) 3 (5.2%) 17 (6.5%) Conclusions: OPCAB reduced postoperative morbidity in ATSI patients. Short-term mortality was comparable between OPCAB and CABG groups. These findings suggest that OPCAB may be a better technique for surgical revascularisation in this group of patients.
Background: Gastrointestinal (GI) complications after cardiac surgery are uncommon, but are assoc... more Background: Gastrointestinal (GI) complications after cardiac surgery are uncommon, but are associated with high morbidity and mortality as well as significant hospital resource utilization. Methods: We analysed a prospectively collected database containing all adult cardiac surgery procedures performed from July 2001 to March 2011 at Monash Medical Centre and Jessie McPherson Private Hospital. Patients with post-operative GI complications were compared to patients without GI complications who were operated in the same period. Results: The incidence of GI complications was 1.1% (61 out of 5382 patients) with an overall 30-day mortality of 33% (versus 3% in the non-GI complication group). The most common complications were GI bleeding, gastroenteritis and bowel ischaemia. Patients who had GI complications were significantly older, had higher incidence of renal impairment, chronic lung disease and anticoagulation therapy and were more likely to be in cardiogenic shock. Emergency procedures, combined coronary artery bypass grafting and valve surgery and aortic dissection cases were more common in the GI complication group. The GI complication group also had higher incidence of return to theatre, renal failure, stroke, septicaemia and multi-organ failure. Conclusions: GI complications after cardiac surgery remain an uncommon but dreadful complication associated with high mortality. Our findings should prompt a high degree of clinical vigilance in order to make an early diagnosis especially in high risk patients. Further studies aiming to identify independent predictors for GI complications after cardiac surgery are warranted. study was to investigate the incidence, pattern and outcomes of GI complications after cardiac surgery in an Australian institution and compare these results to the findings of prior studies. Methods We performed a retrospective review of a prospectively collected database containing all adult cardiac procedures performed from 1 July 2001 to 31 March 2011 at Monash Medical Centre and Jessie McPherson Private Hospital, both tertiary referral centres in metropolitan Melbourne, Australia. Data were prospectively collected as part of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database project. The database records detailed patient demographics, preoperative risk factors, operative technique, post-operative hospital course and CARDIOTHORACIC
Between 1961 and 1991, 23 patients (eight men and 15 women, with a mean age of 50 (range 25-72) y... more Between 1961 and 1991, 23 patients (eight men and 15 women, with a mean age of 50 (range 25-72) years) with cardiac myxomas were managed at the Alfred Hospital, Prahran, victoria, Australia. Symptoms of mitral valve obstruction were present in 13 patients and of systemic embolism in nine. In the patients, 21 myxomas were confined to the left atrium. In the other two patients, one myxoma was confined to the right atrium and the other was a dumb-bell-shaped biatrial myxoma. Most tumours were diagnosed with echocardiography. Removal was achieved via a median sternotomy and by entering the involved chamber. Those myxomas presenting with systemic embolism were always soft and friable, whereas those with obstructive symptoms were large and of variable consistency. There was one operative death early in the series. The 22 surviving patients have been assessed as functional class 1 of the New York Heart Association at follow-up. ranging from 2 months to 23 years (mean 9 years). There were n...
Clinical and Experimental Pharmacology and Physiology, 2021
Acute kidney injury (AKI) is a common and serious post‐operative complication of cardiac surgery.... more Acute kidney injury (AKI) is a common and serious post‐operative complication of cardiac surgery. The value of a predictive biomarker is determined not only by its predictive efficacy, but also by how early this prediction can be made. For a biomarker of cardiac surgery‐associated AKI, this is ideally during the intra‐operative period. Therefore, in 82 adult patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB), we prospectively compared the predictive efficacy of various blood and urinary biomarkers with that of continuous measurement of urinary oxygen tension (UPO2) at pre‐determined intra‐ and post‐operative time‐points. None of the blood or urine biomarkers we studied showed predictive efficacy for post‐operative AKI when measured intra‐operatively. When treated as a binary variable (≤ or > median for the whole cohort), the earliest excess risk of AKI was predicted by an increase in urinary neutrophil gelatinase‐associated lipocalin (NGAL) at 3 h after en...
rax with upper abdomen. After general anaesthesia had been induced with double-lumen tracheal int... more rax with upper abdomen. After general anaesthesia had been induced with double-lumen tracheal intubation, the patient was positioned in right lateral decubitus. Mini-thoracotomy performed over seventh rib extending from anterior costal margin for 4 cm. The myotomy was carried out proximally to the level of the left inferior pulmonary vein and distally for approximately 1.5 cm on the anterolateral portion of the gastric cardia. Chest was closed with single drain chest xray was done in the immediate postoperative period, and then the patient was orally allowed. Mean operative time was 25 minutes. Operative data obtained included duration of surgery, intraoperative complications, and postoperative complications, including perforation, atelectasis, pneumonia, and length of hospital stay. Results: Mortality was nil. Morbidity was four (1.93%), all in the form of atelectasis. There were no leaks. Of 207 patients, 197 had no symptoms after a follow-up of 12 months, whereas eight patients had reflux and seven patients had persistent dysphagia with megaoesophagus. They subsequently underwent oesophagectomy with stomach pull-up. Mean operative time was 25 minutes and mean length of hospital stay was 3 days. Conclusions: Transthoracic Heller myotomy via left anterior mini-thoracotomy for achalasia is a safe and effective procedure giving satisfactory results with minimum operative time, hospital stay, and morbidity and with no mortality.
Introduction: South Africa continues to be burdened by human immunodeficiency virus [HIV] and tub... more Introduction: South Africa continues to be burdened by human immunodeficiency virus [HIV] and tuberculosis [TB]. In Cape Town, the epidemic of HIV-TB co-infection is as high as 70%. Granulomatous interstitial nephritis [GIN] has increased in frequency on renal biopsy. This study aimed to determine GIN prevalence and causes in HIV positive patients as well as renal outcomes, patient survival and associated factors. Methods: This observational cohort study reviewed HIV positive renal biopsies for GIN from 2005-2012. Causes of GIN (medications, TB, fungal and other), and baseline characteristics were analysed. A comparison of baseline data, renal function and survival was made between GIN and non-GIN cohorts. Results: There were 45/316 biopsies demonstrating GIN. TB was the likely cause of GIN in 27 [60%] and 9 [20%] were due to a drug. Low eGFR was statistically significant for mortality in both GIN [p=0.045] and non-GN cohorts [p<0.000]. In the GIN group there were 12 (26.7%) deaths. Mortality for all patients was greatest in the first 6 months [p= 0.057]. TB co-infection in both cohorts was associated with a higher mortality. The final creatinine at 12 months was worse in the GIN group however not significant [p=0.522]. Conclusions: GIN is common in HIV positive renal biopsies in Cape Town. TB-GIN was the commonest cause and associated with a high early mortality. GIN should be considered in HIV positive patients with acute kidney injury, its presence conveys a survival benefit. There is a need for improved diagnostic accuracy and treatment strategies of TB-GIN.
Predominantly based on studies from high-income countries, reduced estimated glomerular filtratio... more Predominantly based on studies from high-income countries, reduced estimated glomerular filtration rate (eGFR) has been associated with increased risk of infections and infection-related hospitalizations (IRHs). We here explore in-hospital outcomes of IRHs in patients with different kidney function. A total of 6,283 adults, not on renal replacement therapy, with a discharge diagnosis of infection, and with an eGFR 1–12 months before index hospitalization, were included from four hospitals in China. We compared in-hospital outcomes (death, intensive care unit (ICU) admission, length of hospital stay (LOHS) and medical expenses), between patients with and without chronic kidney disease (CKD, defined as eGFR ≤ 60 ml/min per 1.73 m2 of body surface area) by mixed-effects logistic regression model or generalized linear model. The odds for in-hospital mortality (adjusted odds ratios (OR) = 1.41; 95% CI 1.02–1.96) and ICU admission (OR = 2.18; 95% CI 1.64–2.91) were higher among patients w...
An increasing proportion of patients present for concomitant aortic valve replacement (AVR) and c... more An increasing proportion of patients present for concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) with left ventricular (LV) dysfunction. The aim of this study was to evaluate the early outcomes and late survival of patients with different degrees of LV function undergoing concomitant AVR and CABG. Between June 2001 and December 2009, patients undergoing concomitant AVR-CABG were identified from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program. Demographic, operative data and post-operative outcomes were compared between patients with normal (> 60%), moderately impaired (30- -60%), and severely impaired (< 30%) estimated LV ejection fraction (LVEF). Independent risk factors for short- and long-term mortality were identified using binary logistic and Cox regression, respectively. AVR-CABG was performed in 2,563 patients with a mean follow up of 36 months (range 0-106). 144 (5.6%) had se...
Journal of cardiovascular medicine (Hagerstown, Md.), 2014
Postoperative atrial fibrillation (POAF) is a known complication of cardiac surgery. There is a p... more Postoperative atrial fibrillation (POAF) is a known complication of cardiac surgery. There is a paucity of data on the effects of POAF on short-term and long-term outcomes after concomitant aortic valve replacement and coronary artery bypass grafting (AVR-CABG ). We retrospectively reviewed data on patients without preexisting arrhythmia who underwent isolated first-time AVR-CABG between June 2001 and December 2009 using the Australasian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program. Preoperative characteristics, early postoperative outcomes and late survival were compared between patients who developed POAF and those who did not. Propensity score matching was performed to account for the differences between the two groups. Isolated AVR-CABG surgery was performed in 2028 patients without preexisting arrhythmias at 18 Australian institutions, of whom 894 (44.1%) developed POAF. POAF patients were generally older (mean age, 75 vs. 73 years, P < ...
The Journal of Thoracic and Cardiovascular Surgery, 2013
Objective: No previous studies have specifically addressed the effect of training on outcomes aft... more Objective: No previous studies have specifically addressed the effect of training on outcomes after concomitant aortic valve replacement and coronary artery bypass grafting. This study evaluated the early and late outcomes after concomitant aortic valve replacement and coronary artery bypass grafting performed by surgeons in training. Methods: A retrospective analysis of data collected prospectively by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database between June 2001 and December 2009 was performed. Concomitant aortic valve replacement and coronary artery bypass grafting was performed in 2540 patients; of these procedures, 290 (11.4%) were by trainees. Patient demographics, intraoperative characteristics, and early morbidity were compared between trainee and staff cases using chi-square analysis and t tests. Multivariate analyses were used to determine the independent association of training status with 30-day and late mortality. Results: Compared with staff cases, trainee cases were younger (mean age, 73.0 vs 74.2 years; P ¼ .025) and less likely to present with triple vessel disease (27.9% vs 38.3%, P ¼ .001) or previous cardiac surgery (6.3% vs 2.8%, P ¼ .016). Trainee cases had longer mean perfusion (160.4 vs 144.6 minutes, P<.001) and crossclamp (125.2 vs 114.6 minutes, P <.001) times. The incidence of early complications was similar between the 2 groups. On multivariate analysis, trainee status was not associated with an increased risk of 30-day mortality (2.4% vs 4.0%, P ¼ .348). Moreover, there was no significant difference in long-term outcomes, and 5-year survival was comparable in both groups (79.6% vs 77.4%, P ¼ .200). Conclusions: Concomitant aortic valve replacement and coronary artery bypass grafting can be safely and effectively performed by properly supervised trainees in the contemporary era. It is imperative to offer training opportunities to junior surgeons in this complex procedure to ensure quality patient outcomes in the future.
conception and design, data acquisition, analysis and interpretation of data, and drafting of the... more conception and design, data acquisition, analysis and interpretation of data, and drafting of the manuscript. Glenda Campbell: conception and design, development of prescribing alerts, testing and verification of the computer application, data acquisition, analysis and interpretation of data, and critical review of the manuscript. Amit X. Garg and Lisa Dolovich: conception and design, development of prescribing alerts, analysis and interpretation of data, and critical review of the manuscript. Jackie B. Stroud: conception and design; data acquisition; analysis and interpretation of data; critical review of the manuscript; coordination of the development, testing, and verification of the computer application. Ruth E. McCallum: critical revision and formatting of the manuscript and final approval of the manuscript. Alexandra Papaioannou: conception and design, development of prescribing alerts, data acquisition, analysis and interpretation of data, and critical review of the manuscript.
Background: There are limited data on the impact of smoking status on outcomes after isolated cor... more Background: There are limited data on the impact of smoking status on outcomes after isolated coronary artery bypass graft (CABG) surgery. Methods: Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program were retrospectively analyzed. Demographic and operative data were compared between patients who were non-smokers, previous smokers, and current smokers. The independent impact of smoking status on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively. Results: Isolated CABG surgery was performed in 21 534 patients; smoking status was recorded in 21 486 (99.8%). Of these, 7023 (32.6%) had no previous smoking history, 11 183 (59.1%) were previous smokers, and 3290 (15.2%) were current smokers. The 30-day mortality rate was 1.8% in non-smokers, 1.5% in previous smokers, and 1.5% in current smokers (p = NS). The incidence of peri-operative complications was generally similar in the three groups, but current smokers were at an increased risk of pneumonia (p < 0.001), and multisystem failure (p = 0.003). The mean follow-up period for this study was 37 months (range, 0-106 months). After adjusting for differences in patient variables, the incidence of late mortality was higher in previous smokers [hazard ratio (HR), 1.73; 95% confidence interval (CI), 1.47-2.05; p < 0.001] or current smokers (HR, 1.41; 95% CI, 1.26-1.59; p < 0.001) compared to non-smokers. Conclusion: Smoking status is not associated with early mortality after isolated CABG. It is, however, associated with an increased risk of pulmonary complications and reduced long-term survival.
Introduction: Pneumothorax caused by apical cysts is a common pathology in young, otherwise healt... more Introduction: Pneumothorax caused by apical cysts is a common pathology in young, otherwise healthy patients. Here we report a case of a young female who was referred to us with a large left spontaneous pneumothorax, refractory to chest drain management, in the setting of first trimester pregnancy. The first and third trimesters of pregnancy are the most dangerous times to administer general anaesthetic, due to the risk of teratogenicity in the former, and preterm labour in the latter, with administration after the 24th week is considered advantageous for foetal viability, in the event of induction of labour. Also, the effects of sclerotic agents such as talcum powder are unknown in pregnancy, with the best evidence available coming from rodents. This case highlights the difficulties in managing pregnant patients with serious conditions where a surgical option exists, and the continuous evaluation of risk vs benefit that must ensue. Methods: A previously fit and well 22 year old G1P0 23 week pregnant female was referred to our service following unsuccessful management of a large left tension pneumothorax with a 12 French intercostal catheter. Subsequent management with large bore chest tube and high suction remained unsuccessful after a further two weeks. Expert obstetric and anaesthetic opinion was sought, due to perceived risk of empyema and blockage of drain with resultant tension pneumothorax (as demonstrated on the ward with a kinked tube on two occasions). Results: After careful consideration, our patient was taken to theatre at 25 + 5/40 for left VATS bullectomy + pleural abrasion. The operation was uneventful, and she was discharged five days later. A healthy baby was born at full term, with the only remaining gestational complication being a case of pyelonephritis requiring antibiotics. Discussion: We present this case together with a series of photographs taken intraoperatively, and a review of the literature regarding treatment of pneumothorax and general anaesthetic in pregnancy. In these cases, risk assessment is vital to ensure the best likelihood of a good outcome for two patients, sometimes with competing demands.
sufficiently to enable circulatory arrest, therefore permitting repair of the arch pathology. How... more sufficiently to enable circulatory arrest, therefore permitting repair of the arch pathology. However, no standardised classification of hypothermia exists for arch surgery, with terms such as 'profound', 'deep', 'moderate', and 'mild' hypothermia used without distinction between institutions. Methods: An international panel of experts, representing high-volume aortic centres from Australia, Asia, Europe, and North America, collaborated and reached the following consensus regarding 'profound', 'deep', 'moderate', and 'mild' hypothermia, based on existing EEG and metabolic studies of brain function. Discrepancies in opinions were resolved by online voting system. Consensus was reached when greater than 50% of the panel concurred on a response. Results: All 14 leading arch surgeons included in the panel agreed upon the classification: profound hypothermia, 14 8C; deep hypothermia, 14.1-20 8C; moderate hypothermia, 20.1-28 8C; and mild hypothermia, 28.1-34 8C. At these temperature ranges, profound, deep, moderate, and mild hypothermia is expected to afford 30-40, 20-30, 10-20, and 10 minutes of 'safe' circulatory arrest duration, respectively (Figure 1). Based on the existing evidence, it is also recommended that arrest temperature be measured at the nasopharynx. Conclusion: A concerted effort is required to standardise much of the nomenclature of aortic arch surgery. Endeavours such as this will facilitate more consistent and valid comparisons between surgical approaches and institutions.
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