The Annals of thoracic surgery
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A patient sustained an episode of hypoxemia during cardiopulmonary bypass. Investigation of the extracorporeal circuit after successful resolution of the problem showed that a white, crystalline substance later identified as mannitol occluded the oxygen supply line to a bubble oxygenator. The management and subsequent investigation of the problem are presented.
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Between January 1975 and June 1988, 156 patients with combined mitral and tricuspid valve disease underwent mitral and tricuspid valve repair or replacement. There were 127 (81%) patients with tricuspid valve repair and 29 (19%) patients with tricuspid valve replacement. Hospital mortality was 14% and was strongly influenced by preoperative pulmonary hypertension (systolic pressure greater than 65 mm Hg) and poor left ventricular function (ejection fraction less than 0.4). ⋯ Ejection fraction was the only age-adjusted risk factor for long-term survival. Of the patients who underwent tricuspid annuloplasty, 91% +/- 4% were free from reoperation after 10 years, indistinguishable from valve replacement (90% +/- 7%). Our tricuspid annuloplasty is simple and effective, and exhibits excellent long-term durability as well as immediate hemodynamic improvement.
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Six consecutive patients with active aortic valve endocarditis, including 2 with extensive subannular aortic root abscess, were successfully treated with viable cryopreserved homograft aortic valve replacement. Two patients required extensive aortic root reconstruction with an appropriately trimmed aortic homograft to cover large abscess cavities. All patients showed resolution of infection with no perioperative mortality or clinically significant morbidity. ⋯ On follow-up at 6 to 48 months, all patients were in New York Heart Association functional class I. The resistance of the unstented homograft to infection makes it an attractive choice for patients requiring aortic valve replacement for active endocarditis. The results of surgical intervention in patients with extensive aortic root involvement may be further improved by the flexibility afforded by the homograft to be "custom-fit" to the abnormal aortic root and the ability to achieve secure abnormal aortic root and the ability to achieve secure valve fixation without use of prosthetic material.
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Internal mammary artery (IMA) bypass grafting to the anterior descending coronary artery was performed in 2,100 patients between January 1978 and July 1986. The average number of additional saphenous vein grafts (SVGs) per patient was 1.8. During the same period, 1,753 patients underwent coronary artery bypass grafting using an SVG (average number of grafts per patient, 3.2). ⋯ However, the long-term probability of cumulative survival and occlusion-free survival were significantly greater and the probability of recurrent angina and reoperative coronary artery bypass grafting were significantly less in IMA graft patients (p less than 0.015). The relative risk of occlusion in an SVG was 4 to 5 times greater than that of the IMA graft. These data indicate that a patent IMA graft to the anterior descending coronary artery protects against recurrent angina and death from cardiac-related causes, and that the IMA should be the conduit of choice.
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Randomized Controlled Trial Comparative Study Clinical Trial
Intraoperative cryoanalgesia for postthoracotomy pain relief.
In a randomized study, 63 patients were investigated for the benefits of cryoanalgesia after thoracotomy. Analgesia and its dependent effects such as enhancement of mobility, respiratory function, and reduced need of narcotics were evaluated. ⋯ However, moderate to severe neuralgia was found in a number of patients in the cryoanalgesia group in the late postoperative period. Cryoanalgesia for pain relief after thoracotomy is not recommended.