The Annals of thoracic surgery
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Many of the components currently used to perform cardiovascular operations lead to systemic insults that result from cardiopulmonary bypass circuit-induced contact activation, circulatory shock, and resuscitation, and a syndrome similar to endotoxemia. Experimental observations have demonstrated that these events have profound effects on activating endothelial cells to recruit neutrophils from the circulation. ⋯ Recently the cellular and molecular mechanisms of endothelial cell activation have become increasingly understood. It is conceivable that once the molecular mechanisms of endothelial cell activation are better defined, therapies will be developed allowing the selective or collective inhibition of vascular endothelial activation during the perioperative period.
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An outbreak of excessive bleeding after cardiac operations occurred at our institution when 5% albumin was in short supply and hetastarch became the preferred intraoperative colloid. As hetastarch may impair coagulation, we investigated the effects of its intraoperative administration on post-cardiac surgical hemostasis. ⋯ Hetastarch infusion just after weaning from cardiopulmonary bypass produces a clinically important impairment in post-cardiac surgical hemostasis. Intraoperative use of this agent during heart operations should be avoided until the safe timing of its administration is clarified.
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Platypnea and Orthodeoxia have been described with congenital heart and severe lung diseases. ⋯ Postpneumonectomy patients complaining of shortness of breath should be assessed for platypnea and orthodeoxia. A right-to-left interatrial shunt through a patent foramen ovale can occur even in the absence of elevated right heart pressures, especially after right pneumonectomy, and is accentuated in the upright posture. Surgical correction of the patent foramen ovale can produce dramatic improvement.
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Case Reports
Anomalous papillary muscle as a cause of left ventricular outflow tract obstruction in an adult.
Left ventricular outflow tract obstruction may be caused by abnormalities of the various structures comprised by the outflow tract. Hypertrophic cardiomyopathy is one of the more common causes, but many are rare anomalies, a collection of which we have compiled. We present a case of left ventricular outflow tract obstruction mimicking aortic stenosis in an adult. This was found to be due to abnormal insertion of a hypertrophied papillary muscle, successfully corrected by mitral valve replacement.
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This study tests the hypothesis that continuous normothermic retrograde blood cardioplegia is superior to cold intermittent blood cardioplegia in protecting the left and right side of the heart transmurally during an extended cross-clamping period. ⋯ These results suggest the following: (1) Chemical arrest is a major contributor of myocardial preservation during diastolic arrest as used in clinical cardiac surgery. (2) Both methods preserve the ultrastructure of the myocytes transmurally during 3 hours of aortic cross-clamping. (3) Both techniques protect the RV and left ventricle; however, to provide optimal protection of the RV, alternated retrograde and antegrade perfusion might be beneficial over retrograde cardioplegia flow alone, in particular with warm cardioplegia.