The Annals of thoracic surgery
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The technique, indications, and results of subxiphoid pericardial window in penetrating chest wounds with suspected traumatic pericardial tamponade are reported. The classic signs of pericardial tamponade (elevated central venous pressure, muffled heart sounds, and paradoxical pulse) are unreliable in an emergency situation. Chest roentgenograms and electrocardiograms are of little diagnostic value. ⋯ There were 4 negative and 46 positive findings of tamponade in 50 consecutive patients with suspected traumatic pericardial tamponade who underwent creation of a subxiphoid pericardial window. There were no deaths or complications from the procedures. The early use of subxiphoid pericardial window has been a major factor in reducing our mortality rate from penetrating heart wounds to 12% overall, and 8% in the past three years.
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Of the first 1,000 consecutive patients in our unit to receive aortocoronary bypass grafts, 108 have died: 32 at operation, 16 in hospital, and 60 late. Of 343 patients who had a normal ventricle, only 1 (0.29%) died at operation, and 2 of the 8 late deaths were noncardiac in cause. Most operative deaths resulted from low cardiac output, and most later deaths were caused by congestive heart failure. A study of the relation of various clinical and operative factors with mortality found that patients with congestive heart failure who underwent valve replacement and bypass grafting had the worst prognosis (73% mortality) while those undergoing bypass grafting with Class III or IV ventricular function (as we define it) and congestive heart failure were next (49% mortality).
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At present there is much interest in the use of surface-induced deep hypothermia with circulatory arrest in infants undergoing an open-heart procedure for repair of congenital defects. This paper presents our experience with infants who have been monitored by preoperative, intraoperative, and postoperative electroencephalograms as well as by preoperative and postoperative neurological assessments. Our results indicate that young infants tolerate deep hypothermia with circulatory arrest quite well, and we therefore continue to advocate use of this procedure in operations for congenital cardiac disease.
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The advancements in extracorporeal cardiopulmonary support through oxygenation and pumping units have permitted the explosive development of heart surgery. A battery-powered portable cardiopulmonary bypass machine has been used in 39 patients whose conditions precluded transport to the operating room. Nineteen patients with massive pulmonary emboli, 10 with extensive cardiopulmonary trauma, who had sustained massive drug overdose, and 2 with cardiogenic shock from acute myocardial infarction were successfully placed on cardiopulmonary bypass at the bedside within 15 minutes of cardiac arrest using femoral artery and femoral vein cannulation. ⋯ Eight of the 10 patients who required portable cardiopulmonary bypass for massive traumatic thoracic injuries had control of hemorrhage and repair, allowing bypass to be discontinued. Two of these 8 patients had sustained transection of the proximal left anterior descending coronary artery. Sixteen patients survived for more than 30 days, and there are 15 long-term survivors.