The Annals of thoracic surgery
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Although the last decade has brought dramatic improvement in patient selection and postoperative management of adults and children undergoing advanced mechanical circulatory support, technological advances have been largely limited to the adult population. Intraaortic balloon pumps are technically feasible, but their efficacy has been questioned and their use has been limited in children. Over the last decade, extracorporeal membrane oxygenation has become the most commonly used method of mechanical circulatory support in children who have severe cardiac failure after cardiac operations. ⋯ Surprisingly, many of these patients did well with left ventricular support only. The overall children's survival rates in the myocardial recovery group are better than those in adults. However, current pediatric devices do not provide support for greater than a few weeks, making bridging to transplantation less feasible than in adults.
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Three myocardial protection techniques were studied in a canine model of acute myocardial ischemia with subsequent revascularization. Eighteen animals were randomly assigned to one of three treatment regimens: cold oxygenated crystalloid cardioplegia (CC), cold blood cardioplegia with modified reperfusate (CB), and continuous aerobic warm blood cardioplegia (WB) (n = 6 per group). Systemic hypothermic cardiopulmonary bypass (28 degrees C), antegrade arrest, and intermittent retrograde and antegrade delivery were used for the CC and CB groups. ⋯ Myocardial injury as assessed by ST segment elevation (millimeters) was less for the WB group (p = 0.03) (WB, 0.4 +/- 0.3; CB, 1.7 +/- 0.2; CC, 1.6 +/- 0.7). Countershocks necessary to restore sinus rhythm after cross-clamp removal were fewer in the WB group (p = 0.03) (WB, 0.8 +/- 0.3; CB, 4.0 +/- 1.2; CC, 5.5 +/- 1.5). In this model of acute global myocardial ischemia, continuous aerobic warm blood cardioplegia has important advantages over two widely used clinical hypothermic protection techniques.
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Total anomalous pulmonary venous connection has been one of the more challenging congenital heart defects in newborns and young infants despite improvements in surgical technique, cardiac anesthesia, neonatal myocardial preservation, and postoperative care. Since 1981, 30 patients with total anomalous pulmonary venous connection have undergone primary total correction. Mean age at operation was 28 +/- 6 days and mean weight, 3.3 +/- 0.7 kg. ⋯ Growth in survivors is closely monitored. The height growth percentile is less than 5% in 15% +/- 8% of survivors and the weight growth percentile, less than 5% in 17 +/- 8%. During the past decade, with a consistent surgical approach to neonates and infants with total anomalous pulmonary venous connection, it has been possible to achieve low early mortality, low attrition, and excellent late results.
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Randomized Controlled Trial Clinical Trial
Platelet protection by low-dose aprotinin in cardiopulmonary bypass: electron microscopic study.
To evaluate the effect of low-dose aprotinin during cardiopulmonary bypass on platelet function and clinical hemostasis, 30 patients undergoing various cardiopulmonary bypass procedures employing bubble oxygenators were randomized to receive either low-dose aprotinin (2 x 10(6) KIU in the cardiopulmonary bypass priming solution, 15 patients [group A]) or placebo (15 patients [group B]). Blood samples were collected before and after cardiopulmonary bypass to assess platelet count and aggregation on extracellular matrix, which was studied by a scanning electron microscope. On a scale of 1 to 4 preoperative mean platelet aggregation grades were similar in both groups (3.8 +/- 0.5 and 3.5 +/- 0.5 for groups A and B, respectively). ⋯ Platelet count was similar in both groups preoperatively and postoperatively. Total 24-hour postoperative bleeding and blood requirement were lower in the aprotinin group (487 +/- 121 mL and 2.3 +/- 1.0 units) than in the placebo group (752 +/- 404 mL and 6.8 +/- 5.1 units; p < 0.01). These results show that the use of low-dose aprotinin during cardiopulmonary bypass provides improved postoperative hemostasis, which might be related to the protection of the platelet aggregating capacity.