Texas Heart Institute journal
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Analysis of blood product use after cardiac operations reveals that a few patients (< or = 20%) consume the majority of blood products (> 80%). The risk factors that predispose a minority of patients to excessive blood use include patient-related factors, transfusion practices, drug-related causes, and procedure-related factors. Multivariate studies suggest that patient age and red blood cell volume are independent patient-related variables that predict excessive blood product transfusion after cardiac procedures. ⋯ A survey of the currently available blood conservation techniques reveals 5 that stand out as reliable methods: 1) high-dose aprotinin therapy, 2) preoperative erythropoietin therapy when time permits adequate dosage before operation, 3) hemodilution by harvest of whole blood immediately before cardiopulmonary bypass, 4) autologous predonation of blood, and 5) salvage of oxygenator blood after cardiopulmonary bypass. Other methods, such as the use of epsilon-aminocaproic acid or desmopressin, cell saving devices, reinfusion of shed mediastinal blood, and hemofiltration have been reported to be less reliable and may even be harmful in some high-risk patients. Consideration of the available data allows formulation of a 4-pronged plan for limiting excessive blood transfusion after surgery: 1) recognize the causes of excessive transfusion, including the importance of red blood cell volume, type of procedure being performed, preoperative aspirin ingestion, etc.; 2) establish a quality management program, including a survey of transfusion practices that emphasizes physician education and availability of real-time laboratory testing to guide transfusion therapy; 3) adopt a multimodal approach using institution-proven techniques; and 4) continually reassess blood product use and analyze the cost-benefits of blood conservation interventions.
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Since 1988, reparative techniques have been used at our institution to treat valvular insufficiency in selected patients with aortic valve disease. The limitations of aortic valve replacement are well recognized; it is this knowledge that has motivated us to find out whether a subgroup of patients who have aortic insufficiency might be candidates for preservation of their native aortic valves. This subgroup includes patients who have leaflet prolapse, perforation, or calcification. We describe our methods of patient evaluation and selection, as well as our surgical techniques for both bicuspid and tricuspid aortic valve repair.
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Case Reports
Transesophageal electrocardiography and adenosine in the diagnosis of wide complex tachycardia.
The diagnosis of wide complex tachycardia based on surface electrocardiography can be difficult. Misdiagnosis occurs frequently and is commonly associated with increased morbidity and mortality. We describe a case of wide QRS complex tachycardia in which transesophageal electrocardiography and intravenous adenosine were used to obtain a reliable diagnosis. These are safe and readily available tools for elucidating the mechanism of wide complex tachyarrhythmias in hemodynamically stable patients.
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Papillary fibroelastoma is a rare cardiac tumor arising most frequently from valvular endocardium. These tumors are clinically important because of their tendency to embolize. ⋯ To our knowledge, only 2 such cases have been reported in the English literature. Our case illustrates the discovery of a rare, but potentially fatal cardiac tumor, successfully removed by surgery.
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Psychiatric consultation to the critically ill cardiac patient focuses on several common problems: anxiety, delirium, depression, personality reactions, and behavioral disturbances. A review of the causes and treatment of anxiety in the coronary care unit is followed by a discussion of delirium in the critically ill cardiac patient. ⋯ After the initial crisis has been stabilized in the critical care unit, the premorbid personality traits of the patient may emerge as behavioral disturbances--particularly as the duration of stay increases. The use of psychiatric consultation completes the discussion.