The Annals of thoracic surgery
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The vascular endothelium plays a critical role in the regulation of coagulation through the constitutive expression and release of anticoagulants and the inducible expression of procoagulant substances. Cardiopulmonary bypass dysregulates this process by activating endothelial cells, initially promoting bleeding and then thrombosis. Endothelial cell activation in response to circulating inflammatory mediators leads to the initiation of coagulation when tissue factor is expressed throughout the intravascular space. ⋯ Finally, cardiopulmonary bypass results in the endothelial release of plasminogen activators, which lead to an increase in systemic fibrinolysis. The diffuse generation of thrombin, driven by the inducible intravascular expression of tissue factor, plays a major role in all of these processes. Efforts to understand the critical role of the endothelium in coagulation may lead to novel therapies to prevent bleeding or thrombosis in cardiovascular surgery patients.
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As the population ages, an increasing number of patients with previous coronary artery bypass grafting (CABG) will require subsequent aortic valve replacement (AVR). This study examined outcome of AVR after previous CABG and reviewed possible indications for valve replacement at the time of initial myocardial revascularization. ⋯ Aortic valve replacement after previous CABG is associated with a mortality that is higher than that seen after repeat CABG or repeat AVR. It seems prudent, therefore, to use liberal criteria for AVR in those patients who require coronary revascularization and who, at the same time, have mild or moderate aortic valve disease.
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Comparative Study
Operation for two-vessel coronary artery disease: midterm results of bilateral ITA grafting versus unilateral ITA and saphenous vein grafting.
Several studies have demonstrated that single internal thoracic artery (ITA) grafting achieves better results than the use of vein grafts alone, but it is less clear whether bilateral ITA grafting produces better long-term results than a single ITA graft to the left descending coronary artery does. ⋯ Although bilateral ITA grafting can be performed with a perioperative risk comparable with that for unilateral ITA and saphenous vein grafting, long-term results (up to 8 years) of surgically treated two-vessel coronary artery disease are not improved by bilateral ITA grafting.
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Comparative Study
Relative importance of prostaglandin/cyclic adenosine monophosphate and nitric oxide/cyclic guanosine monophosphate pathways in lung preservation.
Modulation of vascular tone and platelet and neutrophil function through the prostaglandin/cyclic adenosine monophosphate or nitric oxide/cyclic guanosine monophosphate pathway can benefit lung graft function. The relative importance of these pathways is unclear. ⋯ Lung graft integrity after storage in Euro-Collins solution was better preserved by glyceryl trinitrate than by prostacyclin in this model.
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Fourteen children (ages 2 to 14 years) and 1 adult (32 years) have undergone a modification of the Fontan procedure in which an extracardiac lateral tunnel or conduit is used in combination with staged or simultaneous bidirectional Glenn shunt(s). ⋯ We recommend this extracardiac procedure for all suitable patients undergoing surgical conversion to the Fontan circulation.