The Annals of thoracic surgery
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Review Case Reports
Retrograde coronary sinus cardioplegia in the presence of persistent left superior vena cava.
Administration of retrograde cardioplegia is hampered by the presence of a persistent left superior vena cava, which results in excessive runoff of solution into the persistent left superior vena cava and the right atrium. Technical modifications are described that permitted aortic valve replacement to be performed in a patient with persistent left superior vena cava using only retrograde cardioplegia.
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We hypothesized that ischemic insult to the lung allograft may render it more susceptible to rejection. Left canine single-lung allografts were subjected to usual periods of cold and warm ischemia (4 hours and 1 hour, respectively). Bronchoalveolar lavage and open lung biopsies were performed at 0, 1, 4, and 24 hours and 1 week after transplantation. ⋯ In addition, natural killer cell cytotoxicity increased from 10.2% +/- 13.5% before transplantation to 20.5% +/- 8.6% 4 hours after transplantation (p < 0.03). By 24 hours MHC class II expression became evident and continued to increase while subtle histologic evidence of rejection appeared by 1 week. We conclude that ischemia-reperfusion injury can alter the local bronchopulmonary milieu, thus rendering it more susceptible to the development of rejection.
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Comparative Study
Comparison of cardiac output measured by intrapulmonary artery Doppler, thermodilution, and electromagnetometry.
A Doppler pulmonary artery catheter system (Doppler cardiac output monitor or DOPCOM) that continuously measures instantaneous and mean cardiac output was recently introduced. Because thermodilution (TD) flow measurements may not represent an adequate standard, the present study was designed to compare TD and DOPCOM cardiac output measurements with aortic electromagnetic (EM) flow in cardiac surgical patients. Twenty-one patients scheduled for elective coronary artery bypass grafting were enrolled in the study. ⋯ However, distribution of DOPCOM values was heavily skewed by 3 patients in whom flow measurements immediately after cardiopulmonary bypass were markedly different between the DOPCOM and electromagnetometry, probably because of malposition of the Doppler transducers secondary to partial catheter withdrawal during bypass. Consistent with this theory was the finding that before CPB, the DOPCOM was significantly better than TD in predicting EM flow (median absolute error: DOPCOM, 0.12 L/min, and TD, 0.48 L/min; p = 0.04). Our data suggest that, in general, the DOPCOM shows similar precision to TD for predicting EM flow measurements, although the DOPCOM may underestimate actual flow.(ABSTRACT TRUNCATED AT 250 WORDS)
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Despite continuing improvement in myocardial protection and surgical technique, the repair of complex congenital heart lesions can result in cardiopulmonary compromise refractory to conventional therapy. In a 29-month period, 24 patients (aged 14 hours to 6 years) were treated with extracorporeal membrane oxygenation (ECMO) 28 times for profound cardiopulmonary failure. Four patients required ECMO after each of two cardiopulmonary bypass procedures. ⋯ Serial echocardiograms demonstrated substantial recovery of cardiac function in 18 of 21 instances (86%) of ventricular failure from myocardial dysfunction. Overall, 18 of 24 patients (75%) were successfully weaned from ECMO including all 4 who underwent 2 ECMO treatments. We conclude that ECMO can successfully salvage children who have serious cardiopulmonary failure immediately after a congenital heart operation and that long-term survival is possible after two ECMO treatments.