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In a randomized trial, 4811 patients with atrial fibrillation were assigned to undergo or not undergo left atrial appendage occlusion during cardiac surgery for another indication. At 3 years, 77% of the patients continued to receive oral anticoagulation. At 3.8 years, the risk of ischemic stroke or systemic embolism was significantly lower with occlusion than without it.

Tranexamic acid is an antifibrinolytic drug that reduces bleeding in patients undergoing cesarean section or cardiac surgery. In this randomized trial involving patients undergoing noncardiac surgery, the risk of bleeding was lower with tranexamic acid than with placebo, but noninferiority with respect to cardiovascular complications was not established.

Cardiopulmonary bypass initiates a systemic inflammatory response syndrome that is associated with postoperative morbidity and mortality. Steroids suppress inflammatory responses and might improve outcomes in patients at high risk of morbidity and mortality undergoing cardiopulmonary bypass. We aimed to assess the effects of steroids in patients at high risk of morbidity and mortality undergoing cardiopulmonary bypass. The Steroids In caRdiac Surgery (SIRS) study is a double-blind, randomised, controlled trial. We used a central computerised phone or interactive web system to randomly assign (1:1) patients at high risk of morbidity and mortality from 80 hospital or cardiac surgery centres in 18 countries undergoing cardiac surgery with the use of cardiopulmonary bypass to receive either methylprednisolone (250 mg at anaesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients were assigned with block randomisation with random block sizes of 2, 4, or 6 and stratified by centre. Patients aged 18 years or older were eligible if they had a European System for Cardiac Operative Risk Evaluation of at least 6. Patients were excluded if they were taking or expected to receive systemic steroids in the immediate postoperative period or had a history of bacterial or fungal infection in the preceding 30 days. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcomes were 30-day mortality and a composite of death and major morbidity (ie, myocardial injury, stroke, renal failure, or respiratory failure) within 30 days, both analysed by intention to treat. Safety outcomes were also analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00427388. Patients were recruited between June 21, 2007, and Dec 19, 2013. Complete 30-day data was available for all 7507 patients randomly assigned to methylprednisolone (n=3755) and to placebo (n=3752). Methylprednisolone, compared with placebo, did not reduce the risk of death at 30 days (154 [4%] vs 177 [5%] patients; relative risk [RR] 0·87, 95% CI 0·70–1·07, p=0·19) or the risk of death or major morbidity (909 [24%] vs 885 [24%]; RR 1·03, 95% CI 0·95–1·11, p=0·52). The most common safety outcomes in the methylprednisolone and placebo group were infection (465 [12%] vs 493 [13%]), surgical site infection (151 [4%] vs 151 [4%]), and delirium (295 [8%] vs 289 [8%]). Methylprednisolone did not have a significant effect on mortality or major morbidity after cardiac surgery with cardiopulmonary bypass. The SIRS trial does not support the routine use of methylprednisolone for patients undergoing cardiopulmonary bypass. Canadian Institutes of Health Research.

Hepatoblastoma is the most common childhood liver malignancy. The management of hepatoblastoma requires multidisciplinary efforts. The five-year overall survival is approximately 80% in developed countries. Surgery remains the mainstay of treatment for hepatoblastoma, and meticulous techniques must be employed to ensure safe and effective local control surgeries. Additionally, there have been several advances from both pediatric and adult literature in the way liver tumor surgery is performed. In this review, we highlight important aspects of liver surgery for hepatoblastoma, the management of metastatic disease, and the most current technical advances in performing these procedures in a safe and effective manner.

After 5 years of follow-up in this trial, the rates of the composite outcome of death, stroke, myocardial infarction, renal failure, or repeat revascularization were similar with off-pump and on-pump CABG. There was also no significant difference in cost or in quality of life. Coronary-artery bypass grafting (CABG) reduces the risk of death in patients with extensive coronary artery disease. 1 CABG is usually performed with the use of a cardiopulmonary bypass (on-pump CABG). With this approach, perioperative mortality is approximately 2%, with an additional 5 to 9% of patients having myocardial infarction, stroke, or renal failure requiring dialysis. The technique of performing CABG on a beating heart (off-pump CABG) was developed to decrease the risk of perioperative complications and to improve long-term outcomes; some complications, both perioperative and long term, may be related to the use of cardiopulmonary bypass and to cross-clamping of the . . .

A prospective cohort study of 13,862 patients showed that among those who underwent isolated coronary-artery bypass grafting or aortic-valve replacement or repair, the threshold high-sensitivity cardiac troponin I level (within 1 day after surgery) associated with an adjusted hazard ratio for death within 30 days of more than 1.00 was 5670 ng per liter — 218 times the upper reference limit.

A total of 4752 patients for whom CABG was planned were randomly assigned to undergo the procedure on-pump or off-pump. At 30 days, the rates of death, myocardial infarction, stroke, or renal failure requiring dialysis did not differ significantly between the two groups. Coronary-artery bypass grafting (CABG) reduces mortality in patients with extensive coronary artery disease. 1 CABG has generally been performed with the use of cardiopulmonary bypass (on-pump). With this approach, perioperative mortality is about 2%, with an additional 5 to 7% of patients having complications such as myocardial infarction, stroke, and renal failure requiring dialysis. The technique of operating on a beating heart (off-pump) for CABG was developed to decrease perioperative complications, some of which may be related to the use of cardiopulmonary bypass and to cross-clamping of the aorta associated with the on-pump CABG procedure. Several previous trials have compared off-pump . . .

A total of 4752 patients were randomly assigned to CABG with (on-pump) or without (off-pump) cardiopulmonary bypass. At 1 year, there was no significant difference in neurocognitive function or quality of life or in the composite of death, MI, stroke, or renal failure. Coronary-artery bypass grafting (CABG) reduces mortality among patients with extensive coronary artery disease. 1 CABG is usually performed with the use of cardiopulmonary bypass (on-pump CABG). With this approach, perioperative mortality is about 2%, and myocardial infarction, stroke, or renal failure requiring dialysis develop in an additional 5 to 7% of patients. The technique of performing CABG on a beating heart (off-pump CABG) was developed to reduce perioperative complications, some of which may be related to the use of cardiopulmonary bypass and to the cross-clamping of the aorta associated with the on-pump CABG procedure, and to improve long-term outcomes. A number . . .