The Journal of thoracic and cardiovascular surgery
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J. Thorac. Cardiovasc. Surg. · Aug 1988
Randomized Controlled Trial Comparative Study Clinical TrialDipyridamole preserved platelets and reduced blood loss after cardiopulmonary bypass.
Cardiopulmonary bypass activates and depletes platelets, which may contribute to postoperative bleeding. In addition, activated platelets may be deposited in the coronary vasculature after ischemia and cardioplegia, which may delay recovery of cardiac function and metabolism and may contribute to early bypass graft occlusion. The antiplatelet agent dipyridamole reduces platelet activation and depletion and may decrease postoperative bleeding and transfusion requirements. ⋯ Postoperative blood loss and blood product transfusions were significantly reduced with both oral and intravenous dipyridamole (p = 0.04 by analysis of variance). Dipyridamole preserved platelets and reduced postoperative bleeding. Intravenous dipyridamole resulted in higher platelet counts than oral dipyridamole and may be required to reduce postoperative bleeding in high-risk patients.
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J. Thorac. Cardiovasc. Surg. · Aug 1988
Case ReportsSurgical bypass of the systemic atrioventricular valve in children by means of a valved conduit.
The surgical approach to relief of mitral stenosis in children is still a controversial problem. We describe our experience with four severely symptomatic children in whom a valved conduit from the left atrium to the left ventricle was successfully used to bypass a hypoplastic systemic atrioventricular valve. A left atrial-left ventricular extracardiac conduit was implanted in these patients with a hypoplastic mitral anulus and an adequate left ventricular chamber. ⋯ Postoperative cardiac catheterization performed in all patients 1 month after the operation showed reduced size of the left atrium, a reduction of the left atrial-left ventricular gradient from a mean of 14 mm Hg to a mean of 5 mm Hg, and an increase of the left atrial outlet from a mean diameter of 10.7 mm to 28.7 mm (including the diameter of the native mitral valve plus the internal diameter of the valved conduit). The application of this unconventional operation in children with congenital or acquired stenosis of the systemic atrioventricular valve should be considered when the mitral valve obstruction cannot be relieved by conventional valve repair or replacement. Furthermore, the left atrial-left ventricular conduit does not preclude future alternative surgical options.
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Improvements in mechanical support for profound circulatory collapse have resulted in increasing survival of these critically ill patients. Since 1980, 27 patients aged 3 days to 69 years (mean 34.9 years) who required mechanical circulatory assistance have been followed up after discharge from the hospital. The refractory cardiogenic shock necessitating mechanical support occurred postoperatively in 22 patients (coronary artery bypass in nine, valve replacement in four, correction of congenital heart defects in nine) and with end-stage cardiomyopathy in five. ⋯ Eight patients are employed full time, three are retired, four attend school, three are in preschool, one is a housewife, and one is unemployed but free of symptoms. Only four patients have significant cardiac disability, and one of these still works. In conclusion, mechanical circulatory assistance allows adequate support to permit satisfactory long-term survival in patients with refractory cardiogenic shock.
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J. Thorac. Cardiovasc. Surg. · Jul 1988
Survival, functional status, and reoperations after repair of tetralogy of Fallot with pulmonary atresia.
Among 139 patients who underwent repair of tetralogy with pulmonary atresia, survival rates at 1 month and at 1, 5, 10, and 20 years were 85%, 82%, 76%, 69%, and 58%, respectively. The hazard function (instantaneous risk of dying) was greatest immediately after operation and declined thereafter, but a low constant hazard persisted for as long as the patients were followed up. Multivariately, the postrepair ratio between peak right ventricular and left ventricular pressures measured in the operating room provided the most information relative to the probability of death after repair, and cardiopulmonary bypass time the next. When morphologic abnormalities of the pulmonary circulation were considered in the multivariate analysis for risk factors for death, the size of the pulmonary arteries provided the most information, followed by the number of large aortopulmonary collateral arteries. The postrepair peak right ventricular/left ventricular pressure ratio was lower the day after operation than in the operating room in 65% of the patients in whom the measurements were made. Recurrent or residual ventricular septal defects necessitating rerepair occurred in four patients (3% of hospital survivors). Most surviving patients were in New York Heart Association class I at the time of follow-up. ⋯ Early, intermediate, and long-term survival is less good after repair of tetralogy with pulmonary atresia than after repair of tetralogy with pulmonary stenosis. This is related primarily to the greater prevalence of high peak right ventricular/left ventricular pressure ratio measured in the operating room in the former group. Both the postrepair peak right ventricular/left ventricular pressure ratio in the operating room and the probability of death are inversely related to the size of the pulmonary arteries and directly to the number of large aortopulmonary collateral arteries. This and inferences from other risk factors may be helpful in achieving better results in the future.
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J. Thorac. Cardiovasc. Surg. · Jul 1988
Case ReportsAn outbreak of Pseudomonas cepacia bacteremia associated with a contaminated intra-aortic balloon pump.
In January 1983, symptomatic Pseudomonas cepacia bacteremia developed in two patients in the cardiothoracic intensive care unit within 3 days after cardiac operation and insertion of an intra-aortic balloon pump. An epidemiologic and microbiologic investigation revealed that both patients required intra-aortic balloon pumping for circulatory support and that the water reservoir of the intra-aortic balloon pump (SMEC, Inc., Cookeville, Tenn.) contained more than 10(5) Pseudomonas cepacia per milliliter. This organism was also recovered from the purge button and on-off switch of the pump and from the hands of a health care worker who manipulated the water reservoir of the intra-aortic balloon pump. ⋯ Transmission from the worker's hands to patients presumably occurred by inoculation of the intravascular lines during management. No additional cases of Pseudomonas cepacia bacteremia were observed after the unit was replaced with a nonwater reservior intra-aortic balloon pump. This report substantiates the ability of Pseudomonas cepacia to multiply in water and to cause epidemic bacteremia, identifies the water reservoir of the SMEC intra-aortic balloon pump as a previously unrecognized hazard for the patient requiring intra-aortic balloon pumping, and documents the value of plasmid analysis in elucidating the mode of transmission of nosocomial Pseudomonas cepacia infections.