The Annals of thoracic surgery
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Comparative Study Clinical Trial Controlled Clinical Trial
Effects of aprotinin on hemostatic mechanisms during cardiopulmonary bypass.
Cardiopulmonary bypass (CPB) is associated with activation of humoral systems, which results in the release of proteases. These proteases may affect platelets and stimulate granulocytes. In the present study, the protease inhibitor aprotinin was given in high doses to 11 patients to achieve plasma concentrations of more than 150 kallikrein inactivator units per milliliter during CPB. ⋯ Postoperatively, hemostasis was significantly better preserved after aprotinin treatment (blood loss of 357 ml in the treated group versus 674 ml in the untreated group; p less than 0.01). Since tissue-plasminogen activator activity was similar in both groups, the improved hemostasis most likely should be attributed to platelet preservation. Furthermore, aprotinin lessened neutrophilic elastase release, which might contribute to decreased pulmonary dysfunction in patients at risk.
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Review Case Reports
Survival following nonpenetrating traumatic rupture of cardiac chambers.
We report the cases of 3 patients who survived cardiac chamber rupture resulting from blunt external trauma. All were drivers in motor vehicle collisions. ⋯ The cases of 37 previously reported patients who survived this injury are reviewed. We believe that patients with cardiac rupture who reach the hospital alive can often be saved by prompt diagnosis and immediate surgical treatment.
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Comparative Study
The Blalock-Taussig shunt in infants: standard versus modified.
In recent years, the modified Blalock-Taussig shunt--a polytetrafluoroethylene graft from the subclavian artery to the pulmonary artery--has been preferred over the standard shunt by some surgeons because (1) it requires less dissection and (2) length of native vessels is not critical. From January, 1979, to June, 1985, we operated on 51 infants less than 1 year of age, including 26 less than 1 week of age, to palliate severe complex cyanotic congenital cardiac malformations. Twenty-four modified Blalock-Taussig shunts and 29 standard Blalock-Taussig shunts were created. ⋯ Early and late shunt failure occurred less often with a modified shunt (5/24) than with a standard shunt (15/29) (p less than 0.05). The modified Blalock-Taussig shunt had advantages over the standard Blalock-Taussig shunt in our series: pulmonary artery growth was greater, distortion of pulmonary arteries was less commonly seen, and shunt failure occurred less often. Thus, in infants, we believe the modified Blalock-Taussig shunt should be considered a reasonable alternative to the standard Blalock-Taussig shunt.
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Decreased complement levels and impairment of polymorphonuclear leukocyte function increase the risk of infection during cardiopulmonary bypass (CPB). The effects of different types of oxygenator and of blood suction on this natural humoral and cellular host defense mechanism were investigated in dogs undergoing CPB during sham open-heart operations. Airborne contamination of the wound area and the CPB circuit was performed by aerosolizing Staphylococcus aureus. ⋯ Postoperatively bacteremia developed in no dogs in the membrane oxygenator group, whereas 8 of 15 dogs in the bubble oxygenator group had a positive blood culture for the indicator microorganism. We conclude that the use of a membrane oxygenator is helpful to maintain the host defense. Attention has to be paid to reduce the deleterious effects of cardiotomy suction.
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Twenty-seven patients were examined who were undergoing cardiopulmonary bypass (CPB) surgery with either a bubble oxygenator or a capillary membrane oxygenator. The latter incorporated an arterial filter and bubble trap. A noninvasive Doppler ultrasound technique is described for monitoring irregularities in the Doppler flow signals attributable to gaseous microemboli detected in the middle cerebral artery during CPB. ⋯ However, all 10 patients with a membrane oxygenator had an MEI of 0. Varying the gas flow rates in 3 patients with bubble oxygenators showed a change in MEI from 4 +/- 4 (SD) at a flow rate of 2 L/min to 17 +/- 9 at a flow rate of 5 L/min. This observation supports the assumption that the MEI is providing quantitative information regarding the presence of gaseous emboli in the middle cerebral artery.