Circulation
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Comparative Study
Total bloodless open heart surgery in the pediatric age group.
Forty-eight pediatric open heart surgical procedures were performed with bloodless techniques regardless of surgical complexity or presence of cyanosis at the Children's Hospital of Buffalo. Priming solution for cardiopulmonary bypass was reduced to avoid excessive hemodilution, and careful surgical techniques were used to minimize blood loss. Hypothermia compensated for decreased oxygen-carrying capacity and made it possible to reduce bypass flow safely. ⋯ Four of the smaller infants with complex cyanotic defects needed postoperative transfusion, while 44 patients did not receive transfusion at all during their hospital stay. Total blood product requirement was reduced from 11.5 to 0.35 units per patient. Intracardiac surgery without transfusion is possible in most pediatric patients without evidence of increased risk.
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Abdominal aortic aneurysms are one of the more common problems faced by the vascular surgeon. A review of 898 aneurysms resected at the University of Rochester from 1955 to 1982 revealed a sequential decrease in mortality for elective surgery from 13% in 1955 to 1965, to 8.4% from 1966 to 1973, and 5.6% in the last 8 years. Mortality for resection of ruptured aneurysms remained high (70%). ⋯ Assuming a mortality rate for elective resection of 5% and a mortality rate for resection after rupture of 50%, we estimated that in 1979 +50 million and over 2000 lives could have been saved if patients with abdominal aortic aneurysms had been identified and subjected to elective resection. The incidence of ruptured abdominal aortic aneurysms remains unacceptably high. Mortality from this disease can best be reduced by increased physician awareness and prompt surgical referral.(ABSTRACT TRUNCATED AT 250 WORDS)
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To assess the effects of sodium nitroprusside on the deleterious hemodynamic effects of clamping and unclamping of the aorta during resection of thoracoabdominal aortic aneurysm without the use of a shunt, 50 patients were studied. The risk factors included coronary artery disease (44%) associated with previous myocardial infarction (28%), hypertension (70%), congestive heart failure (6%), chronic obstructive pulmonary disease (34%), asthma (2%), and renal insufficiency (2%). Sodium nitroprusside infusion (3 micrograms/kg/min) was started before clamping and discontinued before unclamping of the aorta. ⋯ During cross-clamping cardiac index in the patients remained unchanged and even increased on unclamping, suggesting that left ventricular function was efficiently protected during these periods. All the patients survived the surgery, and the 30 day mortality was only 4%. Our data indicate that major aortic surgery can be carried out safely with the use of nitroprusside rather than of mechanical techniques to provide proximal decompression.
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Tricuspid valve insufficiency may contribute to a poor hemodynamic result after mitral valve replacement. To determine the role of surgical treatment, we have reviewed the records of 32 adult patients who underwent tricuspid valve repair or replacement 4 months to 14 years after mitral valve replacement. Mild tricuspid valve insufficiency at the time of mitral valve replacement was present in 21 patients (66%); 26 patients (81%) had New York Heart Association class IV disability. ⋯ The high early and late mortality and poor functional outcome for patients undergoing tricuspid valve surgery late after mitral valve replacement contrast with our good overall results in reoperation for prosthetic heart valves. It appears that serious tricuspid valve insufficiency after mitral valve replacement frequently signals right ventricular failure and dilatation; restoring valve competence is palliative. This experience encourages us to continue our policy of liberal indications for tricuspid valve annuloplasty at initial mitral valve replacement.
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In intact chronically instrumented dogs, left ventricular dynamics were studied during cardiopulmonary resuscitation (CPR). Electromagnetic flow probes measured cardiac output and coronary blood flow, ultrasonic transducers measured cardiac dimensions, and micromanometers measured left ventricular, right ventricular, aortic, and intrathoracic pressures. The dogs were anesthetized with morphine, intubated, and fibrillated by rapid ventricular pacing. ⋯ Therefore stroke volume and coronary blood flow in this canine preparation were maximized with manual chest compression performed with moderate force and brief duration. Increasing rate of compression increased total cardiac output while coronary blood flow was well maintained. Direct cardiac compression appeared to be the major determinant of stroke volume during manual external cardiac massage.