Bronchial artery dissection and fatal hemothorax following pneumonectomy

A 59-year-old man died suddenly and unexpectedly two days after an uncomplicated pneumonectomy for bronchogenic adenocarcinoma. In addition to a distal pulmonary thromboembolism found at postmortem, there was significant hemorrhaging into the pneumonectomy space, which was associated with rupture of a dissecting aneurysm in the calcified bronchial artery stump. The pathology and surgical implications of bronchial artery disease are discussed

Transventricular cannulation of the aorta: a useful technique in acute aortic dissection

A 39-year-old morbidly obese man suffered type-A acute aortic dissection. At operation, both external iliac and common femoral arteries were thrombosed. Transventricular cannulation of the ascending aorta provided the only means of maintaining adequate flow on cardiopulmonary bypass (CPB) to support an unusually high body mass index. This method of arterial cannulation for CPB was initially described in paediatric patients. We review the application of this technique in the adult population

Thyroid function during coronary surgery with and without cardiopulmonary bypass

Objective: cardiopulmonary bypass (CPB) is associated with thyroid hormone changes consistent with euthyroid sick syndrome. Similar changes have been observed after general surgical operations. Thyroid hormone changes and their association with global oxygen consumption were studied in low-risk patients undergoing coronary artery bypass grafting (CABG) with and without CPB. Methods: fifty-two patients undergoing primary CABG by the same surgeon were randomised into either on-pump (ONCAB, n = 26) or off-pump (OPCAB, n = 26) groups. Thyroid-stimulating hormone (TSH), free thyroxine (fT4) and free triiodothyronine (fT3) levels were measured at sequential time-points using chemiluminescence assays. Global oxygen consumption was measured at sequential time-points using a continuous cardiac output Swan-Ganz catheter. Results: in both groups TSH and fT4 remained within normal range throughout the study. There was a similar and progressive decline in fT3 levels with no significant difference between the groups over time (p = 0.42). Mean fT3 levels at 24 h were below the normal range and significantly lower than baseline values (ONCAB, 3.3 ± 0.69 pmol/L vs 5.1 ± 0.41 pmol/L, p < 0.001; OPCAB, 3.3 ± 0.51 pmol/L vs 5.0 ± 0.46 pmol/L, p < 0.001). There was a significant inverse relationship between fT3 levels and global oxygen consumption. Conclusions: off-pump surgery is associated with thyroid hormone changes similar to conventional surgical revascularisation. The data suggest that further studies into T3 administration during OPCAB may be warrante

A prospective randomized study to evaluate stress response during beating-heart and conventional coronary revascularization

Background: Cardiopulmonary bypass (CPB) is associated with a systemic stress hormonal response, which can lead to changes in hemodynamics and organ perfusion. We examined perioperative stress hormone release in low-risk patients undergoing coronary artery bypass grafting with and without cardiopulmonary bypass.Methods: Fifty-two patients undergoing primary coronary artery bypass grafting by the same surgeon were randomly assigned into either on-pump (n = 26) or off-pump (n = 26) groups. The on-pump coronary artery bypass grafting group underwent mildly hypothermic (35°C) pulsatile cardiopulmonary bypass with arterial line filtration. Arterial blood samples were collected preoperatively, at the end of operation, and at 1, 6, and 24 hours postoperatively. Plasma levels of vasopressin and cortisol were measured using radioimmunoassay. Anesthetic management was standardized.Results: Both groups had similar demographic makeup and extent of revascularization (on-pump coronary artery bypass grafting, 2.8 ± 1.0 grafts versus off-pump coronary artery bypass grafting, 2.4 ± 0.9 grafts; p = 0.20). No mortality or major morbidity was observed and there were no crossovers. The cardiopulmonary bypass and aortic cross-clamp times in the on-pump coronary artery bypass grafting group were 63 ± 24 and 33 ± 11 minutes, respectively. In both groups there was a similar and significant rise in cortisol and vasopressin levels in the early postoperative phase, with a partial recovery toward baseline values observed at 24 hours postoperatively. Repeated measures analysis of covariance showed no significant difference between the groups with time for both hormones (cortisol, p = 0.40; vasopressin, p = 0.30).Conclusions: Despite the avoidance of cardiopulmonary bypass, off-pump coronary artery bypass grafting surgery triggers a systemic stress hormone response that is comparable to conventional surgical revascularization. The neurohormonal environment during beating-heart surgery should be further explored