The Annals of thoracic surgery
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Case Reports
Distal aortic arch aneurysmectomy and coronary revascularization through a left thoracotomy.
A successful single operation of a distal aortic arch aneurysm and coronary artery disease through a left lateral thoracotomy using a simple hypothermic retrograde cerebral perfusion technique for cerebral protection in a 64-year-old man is reported. During ventricular fibrillation accompanying cooling to 15 degrees C, a left internal thoracic artery was anastomosed with the left anterior descending coronary artery, and the aneurysm was replaced with a patch during hypothermic retrograde cerebral perfusion.
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Prosthetic valve thrombosis is associated with high mortality. The treatment of choice remains operation. This is a case report of the successful combination therapy of tissue plasminogen activator and urokinase for an isolated thrombosed prosthetic mitral valve in a postpartum patient in whom operation was thought to carry an unacceptable risk. Combined thrombolytic therapy or therapy with a single agent with a long half-life and a prolonged infusion time is suggested as an emergent treatment option for prosthetic mitral valve thrombosis.
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Manual cardiopulmonary resuscitation is currently the standard treatment for cardiac arrest patients both in and out of the hospital. Accumulated experimental and anecdotal clinical evidence suggests enhanced survival in patients with extreme circulatory decompensation who have been emergently supported with portable cardiopulmonary bypass. Long-term survival is possible even when application is delayed, but early institution of support after cardiac arrest in selected patients offers the best survival advantages. ⋯ Machinery needed to perform emergency cardiopulmonary bypass is currently available in all hospitals with open heart surgery programs. Simple support is often therapeutic but can also serve as a bridge to definitive diagnostic and other therapeutic procedures. Commercial units are becoming more biocompatible and easier to use, making both wider application and more prolonged support likely in the future.
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Hypothermic total circulatory arrest (CA) is commonly used to facilitate repair of complex congenital heart defects. However, the "safe" period of CA remains to be defined. Extended periods of hypothermic total circulatory arrest may impair cerebral metabolism and cause ischemic brain injury. ⋯ Data were obtained before and immediately after CPB at 37 degrees C, and before and immediately after the experimental period at 18 degrees C. Parameters measured included cerebral blood flow by xenon 133 clearance, arterial and sagittal sinus blood gases, and cerebral metabolism. Hypothermic total circulatory arrest caused an impairment of cerebral metabolism that was directly proportional to CA duration (r2 = 0.73; p = 0.0001), and recovery of metabolic function after 60 minutes of CA improved more than 50% if the head was packed in ice.(ABSTRACT TRUNCATED AT 250 WORDS)
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Eleven cardiac transplant candidates (all male; mean age, 43.3 years) with multiorgan (hepatic, pulmonary, and/or renal) dysfunction were sustained for prolonged periods (> 30 days) with the HeartMate (Thermo Cardiosystems, Inc, Woburn, MA) left ventricular assist device. We evaluated the effect of extended support on end-organ recovery and on the ultimate outcome of cardiac transplantation. In addition to cardiac failure, 9 patients had hepatic dysfunction, 8 had pulmonary dysfunction, and 6 had renal dysfunction (4 of whom required hemodialysis before left ventricular assist device support). ⋯ One patient who required hemodialysis underwent renal transplantation after cardiac transplantation and had complete recovery of renal function. In the current era of donor shortages, gravely ill patients can benefit from a strategy of prolonged left ventricular assist device support. This strategy has proved safe, has allowed for reversal of multiorgan dysfunction, and has produced healthier transplant candidates.