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Background: Volatile anesthetics provide myocardial protection during cardiac surgery. Sevoflurane and desflurane are both efficient agents that allow immediate extubation after off-pump coronary artery bypass grafting (OPCABG). This study compared the incidence of arrhythmias after OPCABG with the two agents. Materials and Methods: Forty patients undergoing OPCABG with immediate extubation and perioperative high thoracic analgesia were included in this controlled, double-blind study; anesthesia was either provided using 1 MAC of sevoflurane (SEVO-group) or desflurane (DES-group). Monitoring of perioperative arrhythmias was provided by continuous monitoring of the EKG up to 72 hours after surgery, and routine EKG monitoring once every day, until time of discharge. Patient data, perioperative arrhythmias, and myocardial protection (troponin I, CK, CK-MB-ratio, and transesophageal echocardiography examinations) were compared using t-test, Fisher′s exact test or two-way analysis of variance for repeated measurements; P < 0.05. Results: Patient data and surgery-related data were similar between the two groups; all the patients were successfully extubated immediately after surgery, with similar emergence times. Supraventricular tachycardia occurred only in the DES-group (5 of 20 patients), atrial fibrillation was significantly more frequent in the DES group versus SEVO-group, at five out of 20 versus one out of 20 patients, respectively. Myocardial protection was equally achieved in both groups. Discussion: Ultra-fast track anesthesia using sevoflurane seems more advantageous than desflurane for anesthesia, for OPCABG, as it is associated with significantly less atrial fibrillation or supraventricular arrhythmias after surgery.

Fast-track anesthesia has gained widespread use in cardiac centers around the world. No study has been published focusing on immediate extubation after aortic valve surgery. This study examines the feasibility and hemodynamic stability of immediate extubation after simple or combined aortic valve surgery using either thoracic epidural analgesia or opioid-based analgesia.Prospective audit, pilot study.Single-institution university medical center.Adult patients undergoing aortic valve replacement (N = 45).Forty-five patients undergoing aortic valve surgery with an ejection fraction of more than 30% were included in this prospective audit. Induction of anesthesia was done using fentanyl, 2 to 4 mug/kg, propofol, 1 to 2 mg/kg, and endotracheal intubation facilitated by rocuronium; anesthesia was maintained using sevoflurane titrated according to bispectral index (BIS [BIS target: 50]). Perioperative analgesia was provided by high thoracic epidural analgesia (TEA group, bupivacaine 0.125%, 6 to 14 mL/h) or fentanyl, up to 10 microg/kg, followed by patient-controlled analgesia with morphine (OPIOID group).Success of extubation within 30 minutes after surgery was recorded. Hemodynamic data during surgery were compared by using an analysis of variance test; p0.05 was considered as showing a significant difference. Data presented as median (25th-75th percentile). In the TEA group, patients underwent simple aortic valve replacement (N = 21) or combined aortic valve surgery (N = 14), with additional coronary artery bypass grafting (N = 10) and replacement of the ascending aorta (Bentall, N = 4). In the OPIOID group, patients underwent simple aortic valve replacement (N = 5) or combined aortic valve surgery (N = 5), with additional aortocoronary bypass grafting (N = 2), replacement of the ascending aorta (Bentall, N = 2), and reconstruction of the mitral valve (N = 1). All 45 patients were extubated within 15 minutes after surgery. There was no need for reintubation; pain scores were lower in the TEA group than in the OPIOID group immediately after surgery and at 6 hours, 24 hours, and 48 hours after surgery. For the TEA group and OPIOID group, the pain scores were 0 (0-2), 0 (0-2), 0 (0-1.5), and 0 (0-0) and 5 (4-5.75), 4 (3-4.5), 4 (3.25-4), and 1 (0-2.5), respectively. During and up to 6 hours after surgery, there was no significant hemodynamic difference between the TEA and OPIOID groups. Eighteen of 45 patients needed temporary pacemaker activation. There were no epidural hematoma or neurologic complications related to TEA.Immediate extubation is feasible after aortic valve surgery using either high thoracic epidural analgesia or opioid-based analgesia; both techniques maintain hemodynamic stability throughout surgery. TEA provides superior pain control.

Bradycardia and hypotension are common during off-pump coronary artery bypass grafting (OPCAB). We present a case of possible reversible global cerebral hypoperfusion during distal grafting of the left circumflex coronary artery. The bispectral index (BIS) suddenly decreased from values of 45-50 to 0 during distal grafting. Neurologic evaluation after immediate tracheal extubation in the operating room was normal and the 58 yr old patient did not suffer any neurologic sequelae. Postoperative recovery was uneventful and the patient was discharged 5 days after surgery. Cerebral hypoperfusion is a possible complication during OPCAB. BIS monitoring in OPCAB could be an indicator of cerebral hypoperfusion.

Background. We present a 15-patient series of awake ‘off-pump’ [without cardiopulmonary bypass (CPB)] coronary artery bypass graft surgery, facilitated by thoracic epidural analgesia (TEA) and femoral nerve block. Methods. Surgery was performed with a conventional median sternotomy. Analgesia was provided with TEA at T1–2 or 2–3 interspace, using bupivacaine 0.5% and sufentanil 1.66 mg ml 21 , initially at 20 ml litre 21 until T1–10 dermatomal block was achieved, then maintained at 2–14 ml litre 21 throughout surgery. Femoral nerve block was performed before operation with neuro-stimulation at the saphenous vein harvest site with 10 ml each of bupivacaine 0.25% and lidocaine 2%. Successful awake surgery, avoiding general anaesthesia (GA) with adequate surgical conditions, without CPB was the primary end point. Results. Fifteen men, mean (SD) age of 63 (9) yr (range 49–81 yr), weight 78 (10) kg, underwent surgery. Three patients (20%) needed conversion to GA: one patient due to insufficient thoracic analgesia, another required initiation of CPB, and the third needed stabilization of the heart for graft suturing due to profound respiratory movements. All three were successfully extubated immediately after surgery. Awake surgery was successful and uneventful in 80% of cases. Conclusions. Combined TEA and femoral block is a novel anaesthetic technique, and is feasible, for cardiac surgery. However, certain technical limitations need to be overcome to evaluate the full potential of ‘awake’ cardiac surgery.

Volatile anaesthetics have gained more popularity recently due to the potential for cardiac protection. Ultra-fast-track anaesthesia implies the immediate extubation after cardiac surgery. The purpose of this prospective randomized double-blind controlled study is to compare the cardioprotective effects of sevoflurane and isoflurane in off-pump cardiac bypass surgery.Forty patients undergoing elective off-pump cardiac bypass surgery with high thoracic epidural analgesia and immediate extubation at the end of surgery were randomized into two groups. During surgery, anaesthesia was provided with either 1 minimum alvelolar anaesthetic concentration of sevoflurane or 1 minimum alvelolar anaesthetic concentration of isoflurane. Troponin-T, creatine kinase-MB, left ventricular wall motion anomalies, time to extubation, respiratory functions and haemodynamic parameters were compared between the two groups by analysis of variance.All patients were successfully extubated in the operating theatre with minimal postoperative pain. Serial creatine kinase-MB and troponin-T concentrations were not significantly different between the two volatile agents. Haemodynamic stability throughout surgery and contractility was not different between groups. However, extubation time was significantly shorter with sevoflurane (10 +/- 5 min) compared to isoflurane (18 +/- 4 min).This study indicates that during off-pump cardiac bypass surgery, sevoflurane and isoflurane provide the same ischaemic cardioprotective effects. There is no difference for heart contractility and haemodynamic values during and after off-pump cardiac bypass surgery between the two agents. Sevoflurane allows a more rapid recovery from anaesthesia, but this does not translate into better pulmonary function or haemodynamics. Both agents are similar in ultra-fast-track off-pump cardiac bypass surgery.

We describe the first published cases of awake cardiac surgery in Canada. In addition, a novel anesthetic technique consisting of combined femoral block/high epidural thoracic anesthesia is presented.Two patients, both 65 yr of age and with good left ventricular function, were scheduled to undergo off-pump coronary artery bypass grafting (OPCAB) for two grafts each. Anesthesia consisted of combined femoral 3:1 block and high thoracic epidural anesthesia. Both surgeries proceeded without hemodynamic or respiratory complications; in both cases, opening of the pleural spaces was treated with insertion of thoracic drainage tubes. Both patients were transferred to the postanesthesia care unit immediately after surgery and six hours later to the cardiac surgical ward. Both patients were discharged from the hospital within five days of surgery.We conclude that awake OPCAB is feasible using a combined femoral block/high thoracic epidural anesthesia technique which allows cardiac surgery and harvesting of the saphenous vein. Further clinical experience is required to define the technical limitations of this technique before randomized studies should be undertaken to better define the role of awake procedures in the future of cardiac surgery.

Background Immediate extubation using thoracic epidural analgesia (TEA) has become more popular after off-pump coronary artery bypass grafting (OPCAB). In this randomized prospective double-blind study, we present the first comparison of preoperative and postoperative haemodynamics during different regimens of TEA for immediate extubation after cardiac surgery. Methods Sixty patients undergoing OPCAB were enrolled in this study. TEA was installed >1 h before application of heparin at levels T2–T4. Analgesia was provided by bupivacaine 0.25%, 8 ml, 15 min before surgery and extubation, and at 10 ml h−1 during surgery and up to 72 h afterwards using one of the following regimens: bupivacaine 0.125% alone, bupivacaine 0.125% with fentanyl 3 µg ml−1 or bupivacaine 0.125% with clonidine 0.6 µg ml−1. Patients were block-randomized for one of the three treatments. Pain scores and infusion rates of TEA were assessed up to 48 h after surgery. Respiratory function was assessed by Pa o 2 and Pa o 2 immediately after surgery, and haemodynamic stability was recorded in the form of heart rate and diastolic and systolic blood pressure. Results Patient characteristics, respiratory function and haemodynamic stability did not vary between the three groups. Pain control was very good and was not significantly different between the groups using similar infusion rates after surgery. Paraesthesia in dermatomes T1 or C8 occurred equally in all three groups. There was no neurological complication related to TEA in this study. Conclusions We conclude that immediate extubation after OPCAB using TEA is feasible with different TEA regimens. Respiratory function, haemodynamic stability and pain control are not different between TEA with bupivacaine alone, bupivacaine with fentanyl or bupivacaine with clonidine.

Purpose: Fast-track anesthesia has gained widespread use in cardiac centers around the world. No study has focused on immediate extubation after aortic valve surgery. This study examines the feasibility and hemodynamic stability of immediate extubation after simple or combined aortic valve surgery using thoracic epidural anesthesia. Methods: Thirty patients undergoing aortic valve surgery with an ejection fraction of more than 30% were included in this prospective audit. After insertion of a high thoracic epidural catheter, induction with fentanyl 2 to 4 microg/kg, administration of propofol 1 to 2 mg/kg, and endotracheal intubation facilitated by rocuronium, anesthesia was maintained with sevoflurane titrated according to bispectral index (target, 50). Perioperative analgesia was provided by high thoracic epidural analgesia (TEA) (bupivacaine 0.125% 6-14 mL/h). Hemodynamic data were compared by Friedman test. P.05 was considered to show a significant difference. Data are presented as median (25th-75th percentile). Results: Patients underwent simple aortic valve surgery (n = 17) or combined aortic valve surgery (n = 13) with additional coronary artery bypass grafting (n = 8), replacement of the ascending aorta (Bentall procedure) (n = 4), and repair of open foramen ovale (n = 1). All 30 patients were extubated within 15 minutes after surgery at 36.5 degrees C (36.4 degrees C-36.6 degrees C). There was no need for reintubation. Pain scores were low immediately after surgery and 6, 24, and 48 hours after surgery at 0 (0-3.5), 0 (0-2), 0 (0-2), and 0 (0-2), respectively. During and up to 6 hours after surgery, there was no significant hemodynamic change due to TEA. Fifteen of 30 patients needed temporary pacemaker activation. There were no complications related to TEA. Conclusions: Immediate extubation is feasible after aortic valve surgery with high thoracic epidural analgesia and maintenance of hemodynamic stability throughout surgery. Immediate extubation after aortic valve surgery is a promising new path in cardiac anesthesia.

To examine the feasibility of immediate extubation after off-pump coronary artery bypass grafting (OPCAB) using opioid based analgesia or high thoracic epidural analgesia (TEA) and compare postoperative analgesia with continuous TEA vs patient-controlled analgesia (PCA).One hundred consecutive patients undergoing OPCAB were included in this prospective audit. After induction of anesthesia using fentanyl 2 to 5 microg.kg(-1), propofol 1 to 2 mg.kg(-1) and endotracheal intubation facilitated by rocuronium, anesthesia was maintained using sevoflurane titrated according to bispectral index monitoring. Perioperative analgesia was provided by TEA (n = 63) at the T3/T4 interspace or T4/T5 interspace using bupivacaine 0.125% 8 to 14 mL.hr(-1) and repetitive boluses of bupivacaine 0.25% during surgery. In patients who were fully anticoagulated or refused TEA, perioperative analgesia was achieved by i.v. fentanyl boluses (up to 15 microg.kg(-1)) and remifentanil 0.1 to 0.2 microg.kg(-1).min(-1), followed by morphine PCA after surgery (n = 37). Maintenance of body temperature was achieved by a heated operating room and forced-air warming blankets.Ninety-five patients were extubated within 25 min after surgery (PCA, n = 33; TEA, n = 62). Five patients were not extubated immediately because their core temperature was lower than 35 degrees C. One patient was re-intubated because of agitation (TEA group); one was re-intubated because of severe pain and morphine-induced respiratory depression (PCA group). Pain scores were low after surgery, with pain scores in the TEA group being significantly lower immediately, at six hours, 24 hr and 48 hr after surgery (P0.05).Immediate extubation is possible after OPCAB using either opioid-based analgesia or TEA. TEA provides significantly lower pain scores after surgery in comparison to morphine PCA.

METHODS. Forty patients undergoing OPCAB with TEA and ultra-fast-track anesthesia were randomized in this pilot study in two groups of 20 patients. Anesthesia was maintained with either 1 MAC of sevoflurane or 1 MAC of desflurane. Continuous ECGmonitoring for the detection of arrhythmias was performed during and up to 72 h after surgery, Troponine-T, CK-MB, regional wall motion abnormalities and ejection fraction, time to extubation, respiratory functions and hemodynamic stability were compared using t-test or Chi-square test. P < 0.05.

To the Editor: We read with great interest the editorial by Dr. Cheng.1 Dr. Cheng questions the economic benefit of immediate extubation after cardiac surgery in our prospective audit.2 He states that the patients being transferred to the postanesthesia care unit (PACU) immediately after extubation needed a nurse cover of a ratio of 1:1 and mentions that this is more intensive than nurse : patient ratio in patients who arrive in the intensive care unit (ICU) intubated. We would therefore like to stress the fact that in our ICU, patients arriving intubated/ventilated from the operating room (OR) are dealt with on a nurse : patient ratio of 1:1, as is the case in the PACU immediately after surgery when the patients arrive extubated from the OR. Therefore, they do not need more nursing care than patients still intubated after cardiac surgery. Dr. Cheng states that thoracic epidural analgesia (TEA) has been reported to provide no improvement in postoperative mobilization, spirometry function and hospital length of stay, based on one study.3 Scott et al.4 conducted a prospective, randomized and controlled study evaluating the incidence of organ complications in 420 patients undergoing routine coronary artery bypass grafting with or without TEA, and found a significantly lower rate of respiratory tract infections, and better pulmonary function as measured in maximal inspiratory lung volume in patients with TEA. Liem et al.5 in another, smaller study, found a significantly higher postoperative PaO2 whenever TEA was used. The authors are surprised by Dr. Cheng’s statement that complications after TEA include pruritus, nausea and vomiting and urinary retention. Pruritus, nausea and vomiting might occur whenever opioids are added to TEA, but are not related to TEA itself in more than 400 cases of TEA with plain bupivacaine in our hospital setting, no patient experienced pruritus or nausea and vomiting related to TEA. Urinary retention might be a complication of lumbar TEA, but seems rather rare with high TEA. High TEA might actually improve renal function,6 or at least not be different from general anesthesia.7 Large multicentre prospective studies are required to further prove the benefits of TEA in cardiac surgery.

INTRODUCTION: Volatile anesthetics provide protection against myocardial ischemia by pharmacologic preconditioning. So far, studies have focused on the effects and outcome of volatile anesthetics and not on comparing different agents. In this randomized, prospective study, we compare the cardioprotective propensities of sevoflurane versus isoflurane OPCAB with the hypothesis that sevoflurane offers superior myocardial protection.

METHODS: Five hundred and eight patients undergoing cardiac surgery with an ejection fraction of at least 25 % were included in this prospectiveaudit. Patients received one of the three regimens of analgesia: analgesia based A) on TEA B) on fentanyl during surgery and po. PCA-morphine or C) bilateral paravertebral blocks + fentanyl during surgery followed by PCA morphine. Anesthesia was induced using fentanyl 2-3 μg/kg, propofol 1-2 mg/kg, and maintained using sevoflurane titrated to a BIS of 40-50. All patient data were recorded; pain scores were compared between the analgesic groups using Kruskal Wallis test, P < 0.05.

To evaluate the clinical performance of the Björk-Shiley Monostrut prosthesis, five centers combined their early experience. Between May, 1982, and June, 1985, 537 prostheses were implanted in 486 patients at these centers: 246 patients had aortic valve replacement (AVR), 163 underwent mitral valve replacement (MVR), and 47 had double-valve replacement (DVR). Thirty patients underwent other, more complex procedures. Concomitant cardiac procedures were performed in altogether 25%. Overall hospital (30 days) mortality was 5.1% (3.6% for AVR, 4.3% for MVR, 8.3% for DVR, and 16.6% for other procedures). The patients were followed up at 6- to 9-month intervals from 6 to 48 months (mean follow-up, 33 months). Follow-up was 99.6% complete. Late mortality was 7.2%. The three-year survival rate was 91.0% for AVR, 92.3% for MVR, and 76.2% for DVR. There was no structural failure of the prosthesis. No instances of valve thrombosis and fatal thromboembolism occurred in anticoagulated patients. The three-year incidence of freedom from thromboembolic events (including TIA) was 89.8% for AVR, 94.9% for MVR, and 90.2% for DVR. Preoperative and postoperative data for the assessment of mechanical hemolysis was available in 60% of the patients. The degree of mechanical hemolysis was low and did not change with time. Although the follow-up is still short, the Björk-Shiley Monostrut prosthesis appears to represent an improvement over previous Björk-Shiley models, particularly with regard to durability.

Twenty-four autologous vein grafts taken from the upper extremities were used in 13 patients undergoing aortocoronary bypass procedures. All of these patients had had previous bilateral saphenous vein stripping. Clinical follow-up between 3 months and 6 1/2 years is reported. Ten patients were recatheterized. There was neither operative mortality nor appreciable morbidity. All the patients are alive and well at the present time. Eleven out of 13 were in New York Heart Association (NYHA) Class I 3 months after operation. Nine patent grafts out of 10 were seen during recatheterization in 6 patients studied less than 9 months after operation. In a subgroup of 5 patients followed for more than 1 year, 2 are now in NYHA Functional Class I, 2 in Class II, and 1 in Class III. Graft patency had been determined in 4 of these patients. Five grafts out of 8 were patent, 2 of them with gross abnormalities. In conclusion, we have some reservations about the long-term fate of these grafts.