The Journal of thoracic and cardiovascular surgery
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J. Thorac. Cardiovasc. Surg. · Oct 1989
Valve replacement in the elderly. Is the mechanical valve a good alternative?
The controversy surrounding the choice of a prosthesis for valve replacement in the elderly patient prompted me to review the performance of mechanical (Medtronic Hall [Medtronic, Inc., Minneapolis, Minn.] and St. Jude Medical [St. Jude Medical, Inc., St. ⋯ Actuarially, global survival (58% +/- 4%) and freedom from reoperation (95% +/- 2%), from thrombotic obstruction (96% +/- 1%), from thromboembolism (92% +/- 2%), from all valve-related mortality and morbidity (82% +/- 3%), and from valve failure (93% +/- 2%) were also similar to those of the younger patients. Mechanical prostheses perform well in elderly patients. I could not confirm an increase in thromboembolic or hemorrhagic episodes, and the respective mortality and morbidity indexes were similar to those observed in younger patients.
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J. Thorac. Cardiovasc. Surg. · Sep 1989
Cardiopulmonary bypass without systemic heparinization. Performance of heparin-coated oxygenators in comparison with classic membrane and bubble oxygenators.
Performance characteristics of heparin-coated hollow-fiber membrane oxygenators (COATED HFMO, n = 5) were evaluated in an open-chest dog model without systemic heparinization. Four other oxygenators were evaluated with standard systemic heparinization (300 IU/kg, activated clotting time more than 400 seconds): a standard hollow-fiber membrane oxygenator (HFMO, n = 5), an inversed hollow-fiber membrane oxygenator (IHFMO, n = 5), a plate membrane oxygenator (PLATE MO, n = 5) and a bubble oxygenator (BUBBLE O, n = 5). The 25 dogs (36 +/- 12 kg) were perfused after cavo-aortic cannulation for 6 hours with a mean flow of 100 ml/kg body weight. ⋯ Determination of fibrin split products during perfusion without systemic heparinization did not show a significant increase. At the end of perfusion all devices were disconnected and gently rinsed with saline: There were no macroscopic clots in the COATED HFMO group perfused without systemic heparin. However, uncoated equipment introduced for control in animals perfused without systemic heparin showed major clotting.(ABSTRACT TRUNCATED AT 400 WORDS)
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Patients with neutral protamine Hagedorn and protamine-zinc insulin-dependent diabetes, a history of fish allergy, or prior vasectomy have been reported to be at an increased risk for protamine reactions after cardiopulmonary bypass because of prior sensitization. We prospectively evaluated cardiac surgical patients with prior vasectomies and fish allergies and retrospectively evaluated a cohort of 3245 consecutive cardiac surgical patients requiring cardiopulmonary bypass over a 2-year period for protamine-containing insulin use and clinical evidence of adverse reactions after protamine administration for heparin reversal after cardiopulmonary bypass. Clinical reactions to protamine did not occur in six patients with fish allergies or 16 patients with prior vasectomies. ⋯ The incidence of clinical reactions in the other patients was 2/3085 (0.06%). The incidence of clinical reactions in the patients with neutral protamine Hagedorn insulin-dependent diabetes is not significantly different from that in other patients. We conclude that prior neutral protamine Hagedorn insulin use, a history of fish allergy, or prior vasectomy does not represent a contraindication to protamine administration after cardiopulmonary bypass.
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J. Thorac. Cardiovasc. Surg. · Jul 1989
Comparative StudyAortic valve replacement with the Hancock standard, Björk-Shiley, and Lillehei-Kaster prostheses. A comparison based on follow-up from 1 to 15 years.
Three series of patients undergoing isolated aortic valve replacement with the standard glutaraldehyde-preserved Hancock porcine bioprosthesis, the standard Björk-Shiley spherical disc prosthesis, and the Lillehei-Kaster tilting disc prosthesis were compared during a 15-year follow-up. From March 1970 to December 1985, aortic valve replacement was performed in 506 patients, 379 men and 109 women, whose ages ranged from 17 to 71 years (mean, 47 +/- 12 years); 196 had a Hancock bioprosthesis, 147 a Björk-Shiley prosthesis, and 163 a Lillehei-Kaster prosthesis. There were no significant differences among the three groups in terms of mean age, preoperative New York Heart Association class, valve lesion, associated intracardiac procedures, and operative mortality (11.7% for the Hancock bioprosthesis group, 8.8% for the Björk-Shiley prosthesis group, and 9.2% for the Lillehei-Kaster prosthesis group). ⋯ There were eight embolic episodes in Hancock valve recipients (0.7% +/- 0.1%/pt-yr), nine in Björk-Shiley prosthesis recipients (1.0% +/- 0.3%/pt-yr), and nine (0.7% +/- 0.1%/pt-yr) in Lillehei-Kaster prosthesis recipients (p = no significant difference). Actuarial freedom from emboli at 15 years is 89% +/- 4% for Hancock, 92% +/- 3% for Björk-Shiley, and 93% +/- 2% for Lillehei-Kaster prosthesis recipients (p = no significant difference). A significant difference was found in the incidence of the following complications. (1) Anticoagulant-related hemorrhage: 0.1% +/- 0.1%/pt-yr for Hancock bioprosthesis, 1.3% +/- 0.3%/pt-yr for Björk-Shiley prosthesis, and 1.9% +/- 0.4%/pt-yr for Lillehei-Kaster prosthesis patients (p less than 0.001), with an actuarial freedom at 15 years of 97.6% +/- 1% for Hancock, 85% +/- 5% for Björk-Shiley, and 68.8% +/- 10% for Lillehei-Kaster recipients (p less than 0.001). (2) Structural deterioration: 3.7% +/- 0.6%/pt-yr for Hancock and none for Björk-Shiley and Lillehei-Kaster patients (p less than 0.001), with an actuarial freedom of 100% for Björk-Shiley prosthesis and Lillehei-Kaster prosthesis patients and 38.4% +/- 12% for Hancock bioprosthesis patients at 15 years.
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J. Thorac. Cardiovasc. Surg. · Jul 1989
Preparation of the internal mammary artery graft. Which is the best method?
Early reports questioned the adequacy of flow of the internal mammary artery when used routinely as a bypass graft. "Adequate" mammary artery flow is now contested only in certain situations, that is, left ventricular hypertrophy, acute myocardial infarction, and reoperations. To compare the methods of mammary pedicle graft preparations with free mammary artery flow, we studied 31 patients who had the left internal mammary artery harvested for elective coronary artery bypass grafting. Group I comprised 14 patients whose mean body surface area was 1.91 m2. ⋯ This study shows that all mammary arteries are in spasm immediately after harvest and that flow is inadequate before any pharmacologic intervention. Although extraluminal vasodilators will increase free mammary artery flow, intraluminal papaverine followed by hydrostatic dilatation raises free flow to maximal capacity. Subsequent graft spasm has not been observed.(ABSTRACT TRUNCATED AT 400 WORDS)