The Annals of thoracic surgery
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Randomized Controlled Trial Clinical Trial
Fresh blood units contain large potent platelets that improve hemostasis after open heart operations.
Twenty units of fresh whole blood were separated into fresh packed red blood cells (PC) and platelet-rich plasma (PRP) and were transfused to 40 patients immediately after coronary bypass grafting. Patients were preoperatively randomized to receive either PRP (group A, 20 patients) or PC (group B, 20 patients). Platelet number in the PRP group was greater, but not significantly greater, than in the PC group (7.5 +/- 3 versus 5.9 +/- 2.2 x 10(10); p = not significant). ⋯ Transfusion of PRP to group A increased platelet count from 128 +/- 20 to 148 +/- 110 x 10(9)/L; however, platelet functions did not improve. Administration of PC to group B increased platelet count from 139 +/- 22 to 156 +/- 23 x 10(9)/L, improved platelet aggregation (with collagen from 33% +/- 20% to 53% +/- 23%, with epinephrine from 36% +/- 24% to 51% +/- 20%; p less than 0.05), and corrected the prolonged bleeding time. The results suggest that the improved hemostasis observed after fresh whole blood administration is related to the large, potent platelets that remained in the PC and were not separated to the PRP during standard platelet concentrate preparation.
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In 1980 we stopped using extracorporeal membrane oxygenation for adults because only 1 of 20 patients treated between 1973 and 1979 survived. In October 1988 we returned to adult extracorporeal life support (ECLS) with a modified protocol including venovenous access when possible, large oxygenators for CO2 clearance, activated clotting time of 180 to 200 seconds, and case selection based on 90% mortality (30% transpulmonary shunt). Of 19 patients referred, 14 met criteria for ECLS. ⋯ One late death occurred at 3 months secondary to intraabdominal complications related to liver transplantation. In conclusion, 10 adult patients with severe respiratory failure were treated with extracorporeal life support; 5 patients recovered lung function and 4 of these patients survived and were discharged to home. Surviving patients were typically younger and were placed on ECLS early in their disease process, emphasizing that early intervention is one key factor to a successful outcome.
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Between 1968 and 1990, we operatively treated 39 patients (19 boys, 20 girls) with congenital aortic arch anomalies. Median age was 7 months (range, 1.5 months to 23 years). Thirty-seven patients (95%) had respiratory symptoms. ⋯ One boy had persistent severe symptoms due to an untreated aortic diverticulum and underwent subsequent excision of the aortic diverticulum with complete relief of symptoms. Median length of follow-up was 12.5 months, with at least 97% of survivors completely or nearly completely free of symptoms from the vascular ring. These results suggest that early repair of congenital aortic vascular rings, including fixating or excising an associated serious aortic diverticulum, is safe and effective and allows for normal tracheal growth.
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The use of profound hypothermia and total circulatory arrest in the surgical treatment of aortic dissection has previously been reported. However, the safe period of prolonged circulatory arrest with hypothermia remains controversial. We have developed a technique of hypothermic total body retrograde perfusion to achieve systemic organ protection: cerebral protection by continuous retrograde perfusion through the superior vena cava, myocardial protection by coronary sinus infusion, and abdominal visceral organ perfusion by continuous retrograde perfusion through the inferior vena cava. Our technique yields a relatively bloodless operating field and avoids hypoperfusion of vital organs through a false lumen.
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Since January 1990, we have performed 29 isolated lung transplantations in 28 patients with end-stage lung disease (12 single, 16 bilateral). Recipient diagnoses were: cystic fibrosis (11), chronic obstructive pulmonary disease (6), pulmonary fibrosis (6), eosinophilic granulomatosis (1), postinfectious lung disease (1), adult respiratory distress syndrome (1), and primary pulmonary hypertension (2). There have been four deaths, two in patients with pulmonary fibrosis and two in patients with primary pulmonary hypertension. ⋯ We have employed bronchial omentopexy in all but four transplants; there has been one partial bronchial dehiscence, two instances of bronchomalacia requiring internal stenting, and one airway stenosis. Cytomegalovirus disease has been seen frequently (15 cases), but has responded well to treatment with ganciclovir. Other complication shave included one drug-related prolonged postoperative ventilation, thrombosis of a left lung after bilateral lung transplantation requiring retransplantation, five episodes of unilateral phrenic nerve palsy after bilateral lung transplantation (4 resolved), and the requirement of massive transfusion (greater than 10 units) in 5 patients.(ABSTRACT TRUNCATED AT 250 WORDS)