The Annals of thoracic surgery
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Comparative Study Clinical Trial Controlled Clinical Trial
Platelet activation in warm and cold heart surgery.
Recent studies suggest that patients undergoing warm heart surgical procedures have reduced postoperative bleeding. To determine if this is due to differences in platelet activation, we measured platelet membrane glycoproteins (GPIb, GPIIb/IIIa, GMP 140), platelet fragments, and platelet counts before, during, and after normothermic (37 degrees C) or hypothermic (28 degrees to 30 degrees C) cardiopulmonary bypass. ⋯ Mean 24-hour postoperative blood loss was 786 +/- 226 mL in the cold group versus 547 +/- 56 mL in the warm group (p = not significant). We conclude that cardiopulmonary bypass affects platelet activation and integrity and that these changes are similar in direction and magnitude for hypothermic and normothermic techniques.
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One-lung ventilation is indicated during thoracic operations for bronchopleural fistula, pulmonary abscess, and pulmonary hemorrhage in spite of the possibility of the development of severe hypoxemia. To evaluate methods for improving oxygen transport during one-lung ventilation, we applied high-frequency jet ventilation (HFJV) and continuous positive airway pressure (CPAP) to the nondependent lung following deflation to atmospheric pressure in each procedure, and measured the effects on cardiac output and arterial oxygenation. In each case, the dependent lung was ventilated with conventional intermittent positive pressure ventilation (IPPV). ⋯ When the chest was open, HFJV maintained satisfactory cardiac output, whereas CPAP usually decreased cardiac output (p < 0.008). There were no significant differences in mean partial pressure of arterial carbon dioxide between HFJV, CPAP, and deflation to atmospheric pressure. In conclusion, HFJV to the nondependent lung provides not only satisfactory oxygenation but also good cardiac output, thereby maintaining better oxygen transport than CPAP or deflation to atmospheric pressure, while the dependent lung is ventilated with IPPV during one-lung ventilation for thoracotomy.
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Review Case Reports
Traumatic tricuspid valve rupture with luxation of the heart.
Three patients are described with the combination of a luxation of the heart through a pericardial tear and traumatic rupture of the papillary muscle of the tricuspid valve. In only 1 patient was the dislocation of the heart suspected preoperatively. In all 3 patients operative treatment was performed with considerable delay after the accident; nevertheless, all 3 patients survived. In all cases treatment consisted of repositioning of the heart, closure of the pericardium, and valvular repair of the tricuspid valve.
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Macroscopic and microscopic emboli of gas, biologic aggregates, and inorganic debris can occur during cardiac operations with cardiopulmonary bypass and may result in end-organ ischemia. In the current era pump-generated embolism is a diminishing cause of perioperative neurologic injury, which now appears to be related mostly to atheroembolism from manipulation of the atherosclerotic ascending aorta, and presents a continuing technical challenge to the surgeon.
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There have been major advancements in cardiac surgery over the past two decades and a concomitant decrease in mortality and major morbidity. The improved safety in cardiac procedures permitted 330,000 operations involving cardiopulmonary bypass in 1992. However, several recent studies have demonstrated that cardiac surgery poses substantial risk of negative neurologic and neuropsychologic outcomes. ⋯ To characterize the incidence and severity of such deficits after cardiac operations, a concise battery of neuropsychologic tests that provides reliable evidence of subtle brain trauma is essential. With an objective, valid measure of brain injury, the etiology of neuropsychologic deficits can be identified and either eliminated or the effects ameliorated. The proper selection and use of neurobehavioral tools provides a basis to evaluate the efficacy of surgical and pharmacologic interventions to further improve neurologic outcome after cardiopulmonary bypass.