Circulation
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Randomized Controlled Trial Comparative Study Clinical Trial
Nafamostat mesilate reduces blood loss during open heart surgery.
Nafamostat mesilate (FUT-175) is a protease inhibitor inactivating coagulation, fibrinolysis, and platelet aggregation. A prospective, randomized trial was performed to assess the efficacy of FUT-175 in the reduction of postoperative bleeding tendency. ⋯ FUT-175 inhibits fibrinolysis and preserves platelet counts and function during CPB and reduces blood loss during open heart surgery.
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Randomized Controlled Trial Comparative Study Clinical Trial
Comparison of cold versus warm cardioplegia. Crystalloid antegrade or retrograde blood?
To evaluate the efficacy of warm versus cold and antegrade versus retrograde cardioplegia, 163 patients were randomized in sequence in three groups and underwent isolated coronary artery bypasses (mean, 4 grafts/patients) alternating in sequence. ⋯ Continuous warm cardioplegia (group 2) did not provide better myocardial protection despite that no CK-MB isoenzyme leak was demonstrated intraoperatively. Intermittent cold crystalloid cardioplegia and cold retrograde provided a clearer operative field and motionless heart. As long as O2 was adequately supplied, under 90 minutes' cross-clamp time, cold crystalloid cardioplegia and cold retrograde blood cardioplegia is safe under hypothermic conditions, whereas warm cardioplegia requires continuous uninterrupted technique with oxygen delivery.
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Heparin rebound, the reappearance of anticoagulant activity after adequate neutralization with protamine, can lead to excessive postoperative bleeding after cardiac surgery. We investigated the mechanism of heparin rebound by using chemically modified heparin that lacks anticoagulant activity (low-affinity heparin) but that is able to displace protein-bound anticoagulantly active heparin. ⋯ Our findings demonstrate that heparin anticoagulant activity persists for up to 6 hours after surgery despite apparent protamine neutralization. The observation of the marked increase in plasma anti-factor Xa activity after the addition of low-affinity heparin suggests that after its administration, a large proportion of the heparin binds to plasma proteins and is incompletely removed by protamine. After protamine is cleared, the protein-bound heparin dissociates slowly and binds to anti-thrombin III to produce an anticoagulant effect.
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Patients undergoing cardiopulmonary bypass (CPB) are known to suffer from a postsurgical systemic inflammatory response, the nature of which remains to be fully elucidated. Interleukin-8 (IL-8) is a newly described, powerful leukocyte chemotactic factor known to be generated after stimulation of interleukin-1 (IL-1). As we have previously documented the generation of IL-1 beta after CPB, it followed that IL-8 generation should be measured in a comparable group of patients. ⋯ The results demonstrated for the first time the presence of cell-associated IL-8 in CPB patients. This suggests that this powerful polymorphonuclear and T-lymphocyte chemotactic factor may be an important element in leukocyte activation and recruitment after CPB.
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Left ventricular outflow tract obstruction (LVOTO) occurs in 4% to 5% of patients after prosthetic ring mitral valve repair. Major anatomic factors incriminated in the genesis of LVOTO include degenerative mitral valve insufficiency with excess leaflet tissue, nondilated left ventricular cavity, and narrow mitro-aortic angle. We have previously reported a 14% incidence of LVOTO after prosthetic ring mitral valve repair in this high-risk group of patients. Serial echo Doppler studies demonstrated an overlapping and/or inversion of the left ventricular functional compartments generating systolic anterior motion of the posterior leaflet and paradoxical opening (eversion) of the anterior leaflet. In an attempt to eliminate LVOTO after mitral valve repair, a new surgical procedure was developed in 1988 by Carpentier: the sliding leaflet technique, which reduces the height of the posterior leaflet. The purpose of this study was to analyze the results of the new technique in terms of the occurrence of LVOTO: ⋯ This study was not done on a concomitant series of patients but on patients with the same type of pathology. It demonstrates that (1) the sliding leaflet technique eliminates significant LVOTO in the high-risk patients; (2) the sliding leaflet technique is associated with a low mortality; and (3) no reoperations for mitral insufficiency were required in this series.