The Journal of thoracic and cardiovascular surgery
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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
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)
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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. · Jun 1989
Comparative StudyProtection of the immature myocardium during global ischemia. A comparison of four clinical cardioplegic solutions in the rabbit heart.
Controversy surrounds the reported beneficial effects of crystalloid cardioplegic solutions in the immature myocardium. In the present study we have investigated the efficacy of four clinical cardioplegic solutions in the immature myocardium to determine (1) whether cardioplegic protection could be demonstrated and, if so, (2) the relative efficacy of the four solutions. Isolated, working hearts (n = 6 per group) from neonatal rabbits (aged 5 to 8 days) were perfused aerobically (37 degrees C) for 20 minutes before a 2-minute infusion of one of four cardioplegic solutions: The St. ⋯ In conclusion, cardioplegic protection can be achieved in the immature rabbit myocardium with both St. Thomas' Hospital and Tyers solutions, but acalcemic solutions such as Bretschneider and Roe solutions (which may be effective in the adult heart) increased damage in this preparation. The reported lack of cardioplegic efficacy in the immature myocardium may therefore reflect the choice of cardioplegic solution rather than a greater vulnerability to injury in the neonatal heart.
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J. Thorac. Cardiovasc. Surg. · May 1989
The effects of deep hypothermic cardiopulmonary bypass and total circulatory arrest on cerebral blood flow in infants and children.
Cardiopulmonary bypass management in infants and children involves extensive alterations in temperature, hemodilution, and perfusion pressure, with occasional periods of circulatory arrest. Despite the use of these biologic extremes of temperature and perfusion, their effects on cerebral blood flow are unknown. This study was designed to examine the relationship of mean arterial pressure and nasopharyngeal temperature to cerebral blood flow during deep hypothermic cardiopulmonary bypass (18 degrees to 22 degrees C) with and without periods of total circulatory arrest. ⋯ These data show that deep hypothermic cardiopulmonary bypass significantly decreases cerebral blood flow because of temperature reduction. Under conditions of deep hypothermia, cerebral pressure-flow autoregulation is lost. This study also demonstrates that cerebral reperfusion after deep hypothermia is impaired if the patient is exposed to a period of total circulatory arrest.