Circulation
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Patients undergoing open heart surgery who have had recent cardiogenic embolic stroke or have central nervous system dysfunction pose a difficult management problem. There is always the risk that cardiopulmonary bypass and heparinization may exacerbate the neurologic injury. There is no clear data indicating what is a safe interval of time from the onset of neurologic symptoms to the time of surgery. ⋯ One patient died in the postoperative period from multisystem failure; all other patients have been followed since discharge (6 months to 4 years). All surviving patients demonstrated improvement in their neurologic symptoms and eight patients had complete neurologic recovery. The results of this study indicate that open heart surgery can be safely performed in patients with recent neurologic injury.
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In cardiac surgery significant residual lesions increase postoperative morbidity and mortality. Although intraoperative epicardial real-time two-dimensional Doppler echocardiography (two-dimensional Doppler) is an accurate and efficient technique for assessing the presence and severity of a residual lesion, it requires placement of a transducer in the operating field and consequent obstruction of the operative procedure. Transesophageal two-dimensional Doppler echocardiography (transesophageal two-dimensional Doppler), which can be applied intraoperatively and postoperatively without such problems, was performed in 35 patients during cardiac surgery (12 patients) and/or at an intensive care unit within 6 hr after cardiac surgery (30 patients). ⋯ In two patients with congenital heart disease, a small residual shunt was detected. In a patient in which a composite valve graft with direct coronary artery reattachment (Bentall's operation) was performed, reattachment was confirmed to be satisfactory. In conclusion, intraoperative and early postoperative monitoring of cardiac function by transesophageal two-dimensional Doppler echocardiography can improve the results of cardiovascular surgery by providing accurate information on cardiovascular structure and blood flow dynamics.
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Between January 1980 and April 1986, 204 patients were hospital survivors after aortic, mitral, or double valve replacement with the St. Jude Medical valve. One hundred ninety patients underwent anticoagulation with modest doses of warfarin (Coumadin), with prothrombin times in the range of 1.3 to 1.5 times control. ⋯ Eighty-seven percent of patients were alive at 5 years and 76.7% of patients were alive and free of all complications at 5 years. We conclude that the St. Jude Medical valve has a low incidence of thromboembolism, hemorrhagic complications, and valve thrombosis in patients receiving modest doses of warfarin.
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Thirteen patients (ages 4 to 16 years) with univentricular heart of right ventricular type, nine with double-inlet right ventricle (DIRV), and four with mitral atresia who underwent a modified Fontan operation were reviewed. Among those with DIRV, right isomerism with a common atrioventricular (AV) valve was found in eight and situs inversus in one; among those with mitral atresia, AV discordance was found in two and concordance in two. Intra-atrial routing using a baffle with atriopulmonary anastomosis was the main procedure (11 patients). ⋯ Preoperative ventricular volume and ejection fraction were not different between those with severely low cardiac output (n = 4, three deaths) and the others, whereas ventricular mass/volume ratio was significantly lower in the former group. Two late deaths (one DIRV, one mitral atresia) related to the AV valve regurgitation. These results may indicate a relatively poor outcome after the modified Fontan operation for patients with univentricular heart of right ventricular type as a result of basic anatomic and hemodynamic problems.
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According to the thoracic pump model of cardiopulmonary resuscitation (CPR), the heart serves as a passive conduit for blood flow from the pulmonary to the systemic vasculature, necessitating an open mitral valve and anterograde transmitral blood flow during chest compression. To assess the applicability of this model to manual CPR techniques, two-dimensional echocardiograms were recorded from the right chest wall and/or the esophagus in nine dogs (18 to 26 kg) during manual CPR. The aortic valve opened with chest compression and closed with release, while the pulmonary and tricuspid valve leaflets closed with compression and opened during release. ⋯ Failure of mitral leaflet approximation during chest compression was observed only when a very low-velocity, prolonged (low-impulse) compression technique was used, or when regions that did not directly overlie the heart were compressed. Consistent with these observations, simultaneous recordings of the left ventricular and left atrial pressures during high-impulse sternal compressions in five dogs (19 to 25 kg) demonstrated peak and mean left ventriculoatrial pressure gradients of 38.5 +/- 4.0 and 13.5 +/- 2.9 mm Hg, respectively, and these pressure gradients declined with less impulsive compressions. The observations made during all but low-impulse chest compressions are inconsistent with the thoracic pump model, and support direct cardiac compression as the primary mechanism of forward blood flow with more impulsive manual chest compression techniques.