The Annals of thoracic surgery
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The cardiopathic patient can sustain acute heart failure during pregnancy. In such cases, if open heart operation is necessary to save the patient's life, the fetus could be seriously compromised after exposure to cardiopulmonary bypass. From 1958 to 1992, 69 reports of cardiac operations during pregnancy with the aid of cardiopulmonary bypass have been published. ⋯ Hypothermia decreases O2 exchange through the placenta. Pump flow and mean arterial pressure during cardiopulmonary bypass seem to be the most important parameters that influence fetal oxygenation. We speculate that cardiac operation is not a contraindication to pregnancy prolongation.
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Development of increasingly complex perfusion devices with bonded heparin allowed for significant improvement of thromboresistance of most basic components required for cardiopulmonary bypass. In his recent review of heparin-coated cardiopulmonary bypass circuits, Gravlee cited 91 references dealing with heparin-coated surfaces, and far more can be found if the search includes material technology or heparin-coated devices not designed for cardiopulmonary bypass (eg, ventricular assist devices, hemofilters, catheters). The present review is focused on long-term application of heparin-coated equipment in conjunction with basic work on heparin bonding relevant for extracorporeal membrane oxygenation. ⋯ However, the longest clinical application of a single device is that of an intravascular gas exchanger that remained fully functional during a 29-day implantation period. Finally, it appears, that circulating protamine interacts with surface-bound heparin. Protamine administration should therefore be avoided during perfusion with heparin-bonded equipment to maintain the improved thromboresistance.
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Blood conservation has become an important issue in cardiac surgery. This study was undertaken to determine if the need of blood transfusion could be predicted from preoperative patient variables. ⋯ These data demonstrate that readily available patient variables can predict patients at risk for transfusion. Routine use of aprotinin and other adjustments of cardiopulmonary bypass should be considered to reduce transfusion in high-risk patients.
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Right-sided circulatory failure remains a significant source of morbidity and mortality for both cardiac transplant and left ventricular assist device recipients. ⋯ Right ventricular assist devices work most effectively if implanted early enough to avoid significant, potentially irreversible end-organ injury. We liberally employ continuous arteriovenous hemodialysis, minimize the use of heparin immediately postoperatively, keep patients sedated, and continue RVAD support until the patient displays signs of hemodynamic and end-organ recovery as heralded by (1) a decrease in central venous pressure and, more importantly, a decrease in pulmonary artery diastolic pressure, (2) an increase in urine output, and (3) a decrease in serum transaminase levels.
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Coronary artery bypass grafting without cardiopulmonary bypass is now an accepted technique of myocardial revascularization. We herein report our total experience with this procedure. ⋯ We conclude that the continuing use of coronary artery bypass grafting without cardiopulmonary bypass is justified and that, with proper selection of patients, the procedure is safe and cost-effective.