The Journal of thoracic and cardiovascular surgery
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J. Thorac. Cardiovasc. Surg. · Jan 1994
Platelet-leukocyte activation and modulation of adhesion receptors in pediatric patients with congenital heart disease undergoing cardiopulmonary bypass.
Cardiopulmonary bypass has been shown in adults to activate platelets and leukocytes, lead to the formation of circulating platelet-leukocyte conjugates, and alter adhesive receptors on both cell types. Pediatric patients with congenital heart disease undergoing cardiopulmonary bypass, however, have not been extensively studied and may represent a group at particular clinical risk for bleeding and pulmonary dysfunction. We studied 13 patients with congenital heart disease undergoing operations necessitating bypass, 7 with cyanotic and 6 with noncyanotic congenital heart disease. ⋯ We conclude that in children with congenital heart disease cardiopulmonary bypass causes loss of platelet adhesion receptors, activation of platelets, formation of platelet-leukocyte conjugates, and leukocyte activation. Cyanotic and noncyanotic patients are qualitatively similarly affected; however, cyanotic patients demonstrate a baseline deficit in the platelet adhesion receptor glycoprotein Ib. These cellular changes may contribute to both the hemostatic and inflammatory complications associated with cardiopulmonary bypass.
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J. Thorac. Cardiovasc. Surg. · Jan 1994
Descending necrotizing mediastinitis. Advantage of mediastinal drainage with thoracotomy.
Descending necrotizing mediastinitis can occur as a complication of oropharyngeal and cervical infections that spread to the mediastinum via the cervical spaces. Delayed diagnosis and inadequate mediastinal drainage through a cervical or minor thoracic approach are the primary causes of a high published mortality rate (near 40%). Between 1985 and 1992, six men (mean age, 49 years) with descending necrotizing mediastinitis were surgically treated at our institution. ⋯ All patients underwent surgical drainage of the deep neck infection combined with mediastinal drainage through a thoracic approach. The outcome was favorable in five patients who had mediastinal drainage through a thoracotomy; the patient who had mediastinal drainage through a minor thoracic approach (anterior mediastinotomy) died of tracheal fistula on postoperative day 18. In our experience, aggressive mediastinal drainage by a thoracotomy approach regardless of the level of mediastinal involvement led to improvement in survival of these patients, with a 17% mortality rate.
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J. Thorac. Cardiovasc. Surg. · Jan 1994
Risk factors for operative mortality and sternal wound infection in bilateral internal mammary artery grafting.
To investigate risk factors for operative mortality and sternal infection in patients undergoing bilateral internal mammary artery grafting, we analyzed the data of 199 patients who underwent this procedure from January 1986 through June 1992. These patients were also compared with those who underwent only saphenous vein grafting (1664 cases) and those who underwent unilateral internal mammary artery grafting (3359 cases) during the same time frame. The operative mortality was 3.52% (7/199) in the patients having bilateral internal mammary artery grafting, 2.71% (91/3359) in those having unilateral internal mammary artery grafting, and 8.53% (142/1664) in the patients having saphenous vein grafting (p < 0.0001). ⋯ We conclude that bilateral internal mammary artery grafting does not increase operative mortality in properly selected patients. However, this procedure should be carefully chosen in elderly (> or = 70 years) patients and for emergency operation. Obese patients have a high risk for sternal infection after bilateral internal mammary artery grafting.
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J. Thorac. Cardiovasc. Surg. · Jan 1994
Endothelin content of bronchoalveolar lavage fluid from allotransplanted pigs is increased during unmodified rejection.
To find a new method for detection of rejection of allotransplanted lungs, we studied the endothelin content of bronchoalveolar lavage fluid by radioimmunoassay. Left-sided lung allotransplantation was performed in pigs. ⋯ The measurements were made from 5, 33, and 11 samples of bronchoalveolar lavage fluid from the rejection, treated, and control groups, respectively. These results suggest that endothelin content of bronchoalveolar lavage fluid could be a marker of lung allograft rejection.
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J. Thorac. Cardiovasc. Surg. · Dec 1993
Randomized Controlled Trial Clinical TrialRight ventricular function after normothermic versus hypothermic cardiopulmonary bypass.
Normothermic systemic perfusion in patients undergoing cardiopulmonary bypass may compromise myocardial hypothermia, a mainstay for preservation of ventricular function during iatrogenic cardiac arrest. The right ventricle is the area of the heart most susceptible to rewarming. We prospectively evaluated myocardial rewarming and indexes of right ventricular function in 30 patients undergoing coronary artery bypass grafting randomized to receive moderate hypothermic (bladder temperature 25 degrees C) or normothermic perfusion and multidose cold blood cardioplegia during cardiopulmonary bypass. ⋯ A right ventricular ejection fraction/volumetric catheter was used to assess right ventricular function by right ventricular ejection fraction and a preload (right ventricular end-diastolic volume) normalized right ventricular stoke work index in the prebypass and postbypass periods. Findings included the following: (1) Greater rewarming of all areas of the heart occurs with normothermic bypass, with the mean temperature difference at the end of each intracardioplegic period ranging from 4.0 degrees to 6.3 degrees C warmer than with hypothermic bypass; (2) the right ventricle was not more susceptible to rewarming than the posterior left ventricle or interventricular septum in either group; (3) right ventricular function did not differ between groups at any time in the study, including the immediate postarrest period; and (4) right ventricular function was preserved and equivalent to the prebypass baseline. We conclude that the moderate myocardial rewarming that occurs with normothermic perfusion does not compromise right ventricular preservation in patients with right coronary artery disease undergoing revascularization with multidose cold blood cardioplegia to maintain electromechanical arrest.