Circulation
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Randomized Controlled Trial Comparative Study Clinical Trial
Hemostatic effects of tranexamic acid and desmopressin during cardiac surgery.
Desmopressin-induced release of tissue plasminogen activator from endothelial cells may explain the absence of its hemostatic effect in patients undergoing cardiac surgery. Prior administration of the antifibrinolytic drug tranexamic acid might unmask such an effect, and combination therapy might thereby improve postoperative hemostasis. ⋯ Desmopressin exerts no hemostatic effect, with or without prior administration of antifibrinolytic drug. Prophylactic tranexamic acid alone appears economical and safe in decreasing blood loss and transfusion requirement after cardiac surgery.
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Randomized Controlled Trial Comparative Study Clinical Trial
A prospective randomized study of a modified technique of ultrafiltration during pediatric open-heart surgery.
Conventional ultrafiltration (UF) fails to reverse satisfactorily hemodilution and the rise in total body water (TBW) seen after cardiopulmonary bypass (CPB). We have modified the technique, timing, and placement of UF in the CPB circuit and in pilot studies observed controlled elevation of hematocrit and a significantly reduced rise in TBW. We have carried out a prospective randomized study in 50 children undergoing open-heart surgery, comparing modified UF (MUF) with nonfiltered controls. ⋯ Percent rise of systolic blood pressure was 1 (-4 to +9) in controls versus 49 (5-81) in MUF (p = 0.0001); percent rise in diastolic blood pressure 0 (-5 to +8) in controls versus 28 (3-47) in MUF (p = 0.0001). UF reduced the rise in TBW and donor blood requirement associated with CPB in children. The blood pressure rise observed during UF is as yet unexplained, but if proven safe the technique may permit donor blood-free cardiac surgery and prevent the accumulation of potentially dangerous excess tissue fluid.
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The effect of diabetes on survival after coronary bypass surgery is uncertain. Also, although the overall clinical benefits of internal mammary artery (IMA) grafting are well established, the survival benefit attributable to IMA grafting in diabetics is not well characterized. To determine the influence of diabetes and IMA grafting on survival after bypass surgery in the current surgical era, characteristics related to subsequent outcome were analyzed in 5,654 consecutive patients undergoing surgery in the decade of the 1980s. ⋯ The magnitude of the survival benefit attributable to IMA grafting in the two groups did not differ (p = 0.4). Diabetes is an important risk factor for late cardiac mortality after bypass surgery and should be included in analyses of the efficacy of therapies for coronary artery disease. IMA grafting conveys a similar benefit to diabetic and nondiabetic patients but does not negate the adverse effect of diabetes on survival.
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The collected data on extracorporeal membrane oxygenation (ECMO), now referred to as extracorporeal life support (ECLS), for pediatric cardiac support has not been analyzed. The purpose of this study was to review the Extracorporeal Life Support (ELSO) Registry data to evaluate the results, identify possible predictors of outcome, and attempt to establish criteria. From 1981 to June of 1990, 189 patients were placed on ECLS for cardiac assist. ⋯ The highest survival, 61%, occurred in right-sided lesions and the lowest, 18%, in post-Fontan. Mediastinal bleeding, cardiac arrest, renal failure, and prolonged intubation were all associated with a poor outcome. Most deaths were attributed to irreversible cardiac or brain injury, suggesting that results could be improved by earlier identification of high-risk patients and earlier institution of ECLS.