摘要:

AbstractOne hundred eleven patients underwent their second to fifth open heart operation, excluding isolated coronary revascularization. The procedures included repeat, single and multiple valve replacements, concomitant redo valve surgery, plus aortic root, and/or aortic arch reconstruction with or without coronary bypass graft. Six patients had heart transplantation as the final procedure. The article is based on the analysis of the experience of one surgeon with particular emphasis on technical considerations and factors enhancing outcome. There were two deaths for an early (hospital—30 days) mortality of 1.8%. There were three sternal wound complications. Two patients suffered cerebrovascular accident (one with permanent residual deficit), and one patient required reoperation for tamponade. The text contains a relatively detailed description of the technical maneuvers applied for several different categories of procedures use

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1995.tb00598.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractTwenty‐three patients, 11 men and 12 women, with a mean age of 64 (range, 34 to 78) underwent aortic valve replacement (AVR) with a CarboMedics®“Top Hat” supraannular prosthesis between March 1993 and August 1994. The top hat supraannular prosthesis, a standard bileaflet valve with the cuff transferred to the valve inflow level, allowed implantation of 21‐mm, 23‐mm, and 25‐mm valves, where a standard 19‐mm or 21‐mm valve would have usually been placed. One patient who had been in preoperative cardiogenic shock died in the perioperative period. Another had an intraoperative cerebral embolism with permanent impairment. Follow‐up on 22 of 23 patients over a mean period of 9 months revealed mean Doppler gradients of 18 ± 6 mmHg, 15 ± 2.8 mmHg, and 11 mmHg, for the 21‐mm, 23‐mm, and 25‐mm valves, respectively. Functional improvement was noted, with 17 patients in New York Heart Association (NYHA) Class I and 6 in NYHA Class II, postoperatively, compared with 0 in Class I, 9 in Class II, 10 in Class III, and 4 in Class IV, preoperatively. One patient showed reduced postoperative ventricular function with fractional shortening below 25%. Pandiastolic regurgitation intrinsic to the valve graded as slight was noted in all patients. Other postoperative complications included one patient with anticoagulant‐related gastrointestinal bleeding and one other with prosthetic valve endocarditis successfully treated with antibiotics. The CarboMedics® top hat valve allows a gain in prosthesis size of 2 mm to 4 mm in the aortic position over standard prostheses, resulting in favorab

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1995.tb00599.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractBetween January 1992 and June 1994, 23 patients underwent surgery for aortic valve endocarditis at the Department of Cardiovascular Surgery of the University of Verona; a subgroup of 10 patients underwent aortic valve replacement with a porcine stentless valve (Biocor LTDA n = 8; Toronto SPV n = 2). There were 7 males and 3 females with a mean age of 56.3 years (range, 36 to 73 years). Eight patients had active endocarditis and two had healed endocarditis. Nine patients had native valve in endocarditis, the presence of a bicuspid aortic valve in 2, and 1 patient had recurrent prosthetic valve endocarditis (PVE), 7 of whom were in New York Heart Association (NYHA) Functional Class IV. The main indications for operation were congestive cardiac failure, active sepsis, and presence of large and mobile vegetations by echo and arrhythmias. There were no operative or late mortalities in this subgroup of patients. Short‐term survival is 100% at a mean follow‐up time of 11.2 months (range, 4 to 18 months), with no recurrent endocarditis or valve‐related complica

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1995.tb00600.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractDespite advances in coronary artery surgery, technical abnormalities remain a significant cause of early graft closure. The development of small fiberoptic angioscopes now allows direct intravascular magnified examination. Seventy‐five distal anastomoses and vein grafts, and five selected coronary arteries were examined with 0.8‐to 2.5‐mm diameter angioscopes introduced through the proximal vein graft while irrigating with clear cardioplegia. Angioscopic findings were correlated with angiographic data, vessel morphology, graft flow, and postoperative course. Satisfactory images were obtained in 72 of 75 anastomotic inspections. Each examination took less than 2 minutes and required less than 100 cc of flush. Angioscopic abnormalities that did not require revision were noted in 17 of 72 anastomoses; intimal flaps in 9, thrombus on posterior wall plaque in 4, intimal irregularities in 4, buckling of posterior wall in 3, and valve near anastomoses in 1. No outflow obstruction nor misplaced sutures were noted. Average flow rate through the grafts with anastomotic angioscopic abnormalities was 33 cc/min versus 40 cc/min in the remaining grafts. However, regression analysis revealed that low‐graft flow was correlated with vessel size and runoff but was not with angioscopic findings. Intracoronary angioscopy revealed discrepancy with angiographic findings in 4 of the 5 examinations. No complications occurred as a result of angioscopy. No graft closure has occurred during early follow‐up. Intraoperative angioscopy can be done with minimal alteration of the usual routine. The 24% occurrence of minor angioscopic abnormalities did not appear to compromise graft flow or earl

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1995.tb00601.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractDue to concerns about complications from normothermic core temperature during cardiopulmonary bypass, we initiated a prospective randomized study of 200 consecutive patients. In one group (group A), both the heart and the body temperature were kept at 37°C. In the second group (group B), both the body and myocardial temperature were allowed to drift down to 34°C. There were no differences between these two groups in age, sex, preoperative numbers of elective, urgent, emergent, redo patients, or coronary artery bypass (CAB), valve, CAB/valve procedures. Their preoperative neurological, pulmonary, renal, and vascular disease status were similar. Preoperative EF was 53% in group A (100 patients) and 52.5% in group B (100 patients). Group A required more volume (p = 0.001) and had less urine output (p = 0.03) during and post bypass. Group A required more phenylephrine hydrochloride (p = 0.05) and had more difficulty managing blood pressure. Strokes and renal failure necessitating dialysis occurred more often in group A but without statistical significance. More difficulties occurred in the normothermic (37°C) group and cardioprotective effects of warm heart surgery may remain intact at 34°C. Mild “drifted/tepid” hypothermic heart surgery could be a better and safer pr

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1995.tb00602.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractThe object of the study was to retrospectively evaluate protective and risk factors for receiving donor blood products and red cell transfusions after coronary and valve surgery performed with a hollow‐fiber oxygenator and with multiple blood‐saving techniques. During the period of January 1991 to June 1993, 1310 patients underwent primary coronary and valve surgery using a hollow‐fiber oxygenator at our institution; the mean age of this population was 61 ±10 years; 977 patients were men (74.6%). Of these patients, 73.5% (963/1310) underwent coronary, 21.5% (281/1310) valve, and 5% (66/1310) combined surgery. Two hundred seventy‐six (21.1%) needed donor blood product transfusions, while 153 (11.7%) patients underwent red cell transfusions. Significant risk factors for homologous blood product exposure after multivariate logistic regression analysis were, in order of importance: (1) postoperative blood loss (O.R. = 1.0009 per mL, p = 0.0000); (2) cardiopulmonary bypass (CPB) time (O.R. = 1.008 per min, p = 0.0001); (3) age at intervention (O.R. = 1.031 per calendar year, p = 0.0026); and (4) reoperation for bleeding (O.R. = 1.71, p = 0.0078). Protective factors were: (1) male gender (O.R. = 0.56, p = 0.0000); (2) preoperative withdrawal of autologous blood (O.R. = 0.66, p = 0.0018); and (3) a preoperative hematocrit greater than 34% (O.R. = 0.76, p = 0.005). When considering risk factors only for donor red cell exposure, multivariate regression analysis identified the following risk factors: (1) reoperations for bleeding (O.R. = 2.04, p = 0.0002); (2) postoperative blood losses (O.R. = 1.0007 per mL, p = 0.0005); (3) CPB time (O.R. = 1.0075 per min, p = 0.0008); and (4) age at intervention (O.R. = 1.03 per calendar year, p = 0.0160). Protective factors were: (1) intraoperative “high‐dose” aprotinin administration (O.R. = 0.61, p = 0.0024); and (2) preoperative donation if autologous blood (O.R. = 0.65, p = 0.0093); and (3) intraoperative withdrawal of autologous blood by phlebotomy (O.R. = 0.67, p = 0.0114). Applying multiple blood‐saving techniques, coronary and valve procedures can now be performed with a low incidence of postoperative donor blood products and red cells exposures; autologous blood predonation and aprotinin administration were highly effective in reducing postoperative t

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1995.tb00603.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractThe value and utility of transesophageal echocardiography (TEE) in unstable cardiac surgical patients have been assessed; 119 TEE studies were performed and evaluated in the emergency setting. The studies were performed in the cardiac surgical intensive care unit (n = 62) and in the operating room (n = 57). There were 81 men and 38 women with a mean age of 58.2 years. The indications for TEE were as follows: hypotension refractory to conventional treatment (n = 83); prosthetic or native valve dysfunction (n = 25); and suspected aortic dissection (n = 10). TEE provided valuable diagnostic information in 107 patients and was completely normal in 12 patients. Based on these results 22 patients had urgent surgical intervention without further studies. The average time to diagnosis was 11.2 minutes. No significant complications were noted. Our results suggest that TEE is highly diagnostic for most of the abnormalities responsible for hemodynamic instability in the perioperative period and facilitates decision making in cardiac surgical emergencies.

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1995.tb00604.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractTwelve bilateral skeletal muscle ventricles (SMVs) were constructed in six dogs by wrapping each latissimus dorsi muscle around a cylindrical, plastic mandrel (volume 30 cc). After 6 to 10 weeks, five dogs had one of their SMVs seeded with allogeneic cultured canine endothelial cells (8 times 106cells/pouch) via an open technique, while the contralateral SMV was seeded by percutaneous injection of cells into the space around the mandrel. After 1 week, the SMVs were excised. Viable, adherent endothelial cells were present in all seeded pouches; this was confirmed via fluorescent microscopy with several endothelial cell markers: KLH‐2, dilacetylated low‐density lipoprotein and antibodies to von Willebrand factor. The inner lining of the SMVs were also examined with scanning and transmission electron microscopy; the highest concentration of cells were seen at the apex where a continuous endothelial monolayer was observed. No significant difference in the distribution or the morphology of the endothelial lining was noted between the open and percutaneous seeding techniques. These data show that SMVs can be seeded with an endothelial monolayer using both open and percutaneous techniq

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1995.tb00605.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractSince January 1992, we adopted a new method of myocardial protection: warm blood cardioplegia with continuous ante‐retrograde combined delivery during normothermic cardiopulmonary bypass, (CPB) instead of cold blood intermittent cardioplegia plus topical ice slush in hypothermic CPB. We have compared postoperative chest X‐rays of 50 patients who underwent elective coronary artery bypass with normothermic CPB to postoperative chest X‐rays, of 50 patients operated upon with hypothermia. In the cold group transitory diaphragmatic paralysis, as well as pleural effusions and thoracentesis related to the hypothermia, and topical cooling, were statistically increased over that of the warm group. The data suggest that topical cooling with slush ice is responsible for phrenic nerve injury and that warm heart surgery has no associated incidence of diaphragmatic i

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1995.tb00606.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractAortic friability is a problem of great concern and frustration for those performing operations on patients with ascending and arch aortic aneurysms, and particularly, on patients with annuloaortic ectasia. We have used 25% glutaraldehyde to successfully strengthen the distal aorta of three such patients. After the application, the aortic wall held sutures without tearing. Postoperative bleeding was minimal in each case. No neurological events were noticed, and all of the patients were discharged home within 2 weeks. The application of this tanning solution to such a friable aortic tissue should be considered as a helpful alternative to reduce postoperative bleeding, which is the most common complication after this type of surgery.

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1995.tb00607.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY