The Journal of thoracic and cardiovascular surgery
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J. Thorac. Cardiovasc. Surg. · Feb 1988
Management of penetrating lung injuries in civilian practice.
Recent reports of military thoracic injuries have advocated early thoracotomy and aggressive management of pulmonary injuries with resection as opposed to the more conservative and traditional treatment with chest tube thoracostomy. A retrospective study was therefore performed to determine the incidence of thoracotomy and lung resection in civilian injuries and to evaluate the effectiveness of treatment of these injuries. Between 1973 and 1985, in a series of 1,168 patients, there were 384 gunshot wounds and 784 stab wounds to the thorax. ⋯ Mortality for all thoracic injuries was 2.3%: for those treated with chest tube alone, 0.7%; for pulmonary hilar injuries, 30%; for pulmonary parenchymal injuries, 8.6%; and for injuries necessitating lung resection, 28%. Most civilian lung injuries can be treated by tube thoracostomy alone. Although relatively few patients with primary pulmonary injury require thoracotomy, those that do are at significant risk and may require lung resection to control bleeding or hemoptysis or to remove destroyed or devitalized lung tissue.
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J. Thorac. Cardiovasc. Surg. · Feb 1988
Comparative StudyInadequate myocardial protection with cold cardioplegic arrest during repair of tetralogy of Fallot.
Postoperative low cardiac output is the most common cause of death in patients undergoing elective repair of tetralogy of Fallot. The incidence is much higher than in elective adult bypass operations for coronary artery disease. To explain this difference, we investigated 16 children having elective repair of tetralogy (mean age 6.3 years). ⋯ Microscopic study revealed focal myocyte necrosis in tetralogy of Fallot. Our findings, which demonstrate inadequate myocardial protection of patients with tetralogy during repair, with depression of adenosine triphosphate and increased lactate during ischemia and reperfusion, suggest a defect in oxidative metabolism. The drop in adenosine triphosphate after reperfusion in the patients with tetralogy implicates reperfusion injury as a mechanism of myocardial damage.
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J. Thorac. Cardiovasc. Surg. · Jan 1988
Anatomic repair of anomalies of ventriculoarterial connection associated with ventricular septal defect. II. Clinical results in 50 patients with pulmonary outflow tract obstruction.
From November 1980 to November 1985, 50 patients underwent anatomic repair of anomalies of ventriculoarterial connection associated with ventricular septal defect and pulmonary outflow tract obstruction. The technique used was one that we have previously described, which we call REV. The principles of this technique are resection of the infundibular septum, construction of a tunnel connecting the left ventricle to the aorta, and direct anastomosis, without a prosthetic conduit, of the pulmonary arterial trunk with the right ventricle. ⋯ No stenosis of the aortic outflow tract was found. Four patients had significant pressure gradients on the pulmonary outflow tract. Our present experience with REV suggests that this technique allows anatomic repair in a wide variety of anomalies of ventriculoarterial connection associated with ventricular septal defect and pulmonary outflow tract obstruction, even in infants, with an acceptable rate of mortality and morbidity.
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J. Thorac. Cardiovasc. Surg. · Jan 1988
Systemic-pulmonary polytetrafluoroethylene shunts in palliative operations for congenital heart disease. Revival of the central shunt.
The concept of central shunting in smaller children with the Waterston shunt was initially well accepted. It has been abandoned because of the difficult estimation of lumen size, preferential flow to the right side, and difficulty in the take-down of the shunt. We have replaced the Waterston shunt with a short segment of polytetrafluoroethylene between the ascending aorta and the main pulmonary artery. ⋯ We have modified our technique so that (1) graft length is less than 0.5 cm and both ends are beveled, (2) the aortotomy is fashioned with a punch, (3) the center of the polytetrafluoroethylene graft is never clamped, (4) heparin is given during the construction of the shunt, and (5) aspirin (10 mg/kg/day) is administered daily. Patency ranges from 1 to 4 years. We conclude that the polytetrafluoroethylene shunt provides excellent palliation and that the central shunt, in the smaller child and infant, offers the benefits of shunting without distortion of the peripheral pulmonary arteries.
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J. Thorac. Cardiovasc. Surg. · Jan 1988
Cerebral autoregulation during deep hypothermic nonpulsatile cardiopulmonary bypass with selective cerebral perfusion in dogs.
We evaluated effects of hypothermic cardiopulmonary bypass on the cerebral circulation and metabolism of six dogs over a temperature range of 37 degrees to 20 degrees C under alphastat acid-base regulation (uncorrected for body temperature). Cerebral metabolic rate for oxygen was determined from the difference between arterial and sagittal sinus blood oxygen contents, and direct cerebral blood flow measurements of the venous outflow from the isolated sagittal sinus. After core cooling at a constant perfusion flow rate of 80 ml/kg/min, cerebral blood flow significantly reduced to 10.0 +/- 1.1 ml/100 gm/min at 20 degrees C (20% +/- 2% of that at 37 degrees C) because of an increase in the cerebral vascular resistance (339% +/- 48%). ⋯ Cerebral metabolic rate for oxygen also kept a constant level down to 30 mm Hg, then fell abruptly. Definite autoregulatory response was detected even in profound hypothermic nonpulsatile cardiopulmonary bypass. These results suggest that cerebral perfusion flow should be regulated so as to keep the perfusion pressure within the range of cerebral autoregulation to prevent cerebral ischemia or hyperperfusion, especially during selective cerebral perfusion for operations on the aortic arch.