The Annals of thoracic surgery
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The public's and surgeons' perception of minimally invasive operations are frequently at odds. Nevertheless, real or perceived benefits may result from limiting skin and skeletal trauma. ⋯ On the basis of this initial experience, we attempt all congenital cardiac and isolated adult valve operations through ministernotomy.
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Reexploration of the mediastinum for bleeding is required in 3% to 7% of patients after cardiac operation, with many proving to have no surgically correctable cause. In spite of a "negative exploration," the bleeding often ceases. We propose the hypothesis that such a negative exploration can be therapeutic by reducing marked fibrinolytic activity in the mediastinal cavity. ⋯ Our data confirm that fibrinolytic activity can be extremely high in the mediastinum in response to clot formation. This may explain the hemostatic effects of a negative reexploration, where irrigation and the removal of clots may reduce the fibrinolytic process; this may allow the bleeding ends of capillaries and small vessels to thrombose. Decreased levels of alpha2-antiplasmin observed suggest that lysine analogs, such as epsilon-aminocaproic acid, may have a beneficial role when locally delivered into the mediastinum.
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A case of traumatic right lung herniation to an area of anterior costal sternal separation and right hemothorax is presented. Application of a thoracoscopic approach to a traumatic lung hernia of the chest wall in this case is discussed.
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The development of systems that allow cardiopulmonary bypass have been responsible for the growth of our specialty. In recent years continuing reduction in the mortality associated with cardiac operations has reinforced our confidence in the reliability and safety of perfusion equipment. Cardiac surgeons are aware that the mortality for most cardiac surgical procedures has decreased dramatically and overall morbidity has been reduced significantly. ⋯ These mechanisms interrelate and produce synergistic, cumulative effects on brain function during and after the operation. Reducing the incidence and effects of this altered brain function will rely on both preventive and therapeutic strategies. These, in turn, must be based on an understanding of the pathophysiology of these mechanisms of cerebral injury and directed toward ways to optimize cerebral perfusion, minimize embolic vascular occlusion, and develop pharmacologic approaches to modify the systemic inflammatory response.
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Deep sternal wound infection (DSWI) is a serious complication of cardiac operations performed by median sternotomy. We attempted to define the predictors of DSWI and to describe the outcomes of two treatment strategies used at our institution. ⋯ Male sex and diabetes are predictors of DSWI in all cardiac surgical patients. Bilateral internal thoracic artery grafting may be contraindicated in diabetic patients.