The Annals of thoracic surgery
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Biography Historical Article
In memoriam: Nina S. Braunwald, 1928-1992.
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Randomized Controlled Trial Clinical Trial
Heparin-coated circuits reduce the inflammatory response to cardiopulmonary bypass.
Cardiopulmonary bypass generates a systemic inflammatory response including the activation of the complement cascade and leukocytes contributing to postoperative morbidity. To evaluate whether the use of heparin-coated extracorporeal circuits could reduce these activation processes, we performed a study on 30 patients undergoing coronary artery bypass grafting who were randomly perfused with a heparin-coated circuit (Duraflo II, n = 15) or with a similar noncoated circuit (control, n = 15). Standardized systemic heparinization was applied for every patient before cardiopulmonary bypass. ⋯ The pattern of complement activation, likely initiating this inflammatory reaction, was modified by heparin coating in two different aspects. There was a significant reduction of C3a generation after protamine administration in patients perfused with heparin-coated circuits, and there was a decrease of complement hemolytic capacity in pooled human serum incubated with heparin-coated tubing. These observations suggest that heparin coating might bind some of the complement components from the classic pathway, thereby reducing the inflammatory response to cardiopulmonary bypass.
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Because the left upper lobe bronchus overlies the left pulmonary artery (PA), T2-3 lesions, N0-1 disease, or rarely inflammation may involve this vessel, necessitating lobectomy with partial PA resection or pneumonectomy with sacrifice of the lower lobe. In 486 operations performed for left upper lobe lesions between 1966 and 1992 (wedge, 111; segmentectomy, 131; lobectomy, 155; pneumonectomy, 89), isolated PA encroachment was caused by bronchogenic carcinoma (32), invasive aspergillosis (2), or organized pneumonitis (1) and occurred in 9% (32/360) of malignant left upper lobe tumors and 2% (3/126) of benign lesions. Initially (1966 through 1979), PA involvement was the indication for 30% (18/60) of left pneumonectomies. ⋯ Paneled saphenous vein interposition was used (3) or 18-mm polytetrafluorethylene tube prostheses (3). All patients survived, 1 later requiring completion pneumonectomy for bronchostenosis after wedge bronchoplasty. Two have since died of metastases or pulmonary insufficiency; the remainder (average follow-up, 17 months) are asymptomatic with lower lobe function in 3 confirmed by differential ventilation-perfusion scans and pulmonary angiography.
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Review
The role of the gut in the development of multiple organ dysfunction in cardiothoracic patients.
Interest in the importance of the gut after injury or operation has waxed and waned over this century. Recent studies implicate the gut in septic complications and multiple organ failure after trauma, operations including cardiothoracic procedures, starvation, and other serious illnesses. Changes in the gut in sick patients include stress ulceration, bacterial overgrowth from stress ulceration prophylaxis, mucosal atrophy, loss of barrier function, increased permeability, and bacterial translocation. ⋯ Louis University Hospital from 1985 to 1991, multiorgan failure developed in 128 patients, with a mortality of 78%. Significant gastrointestinal problems occurred and contributed to multiorgan failure in a number of these patients. Support of the gastrointestinal tract and the prevention of multiorgan failure are important for the cardiothoracic surgeon.