The Annals of thoracic surgery
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An interesting observation, ie, the coracoclavicular line (from the lower border of the coracoid process to the upper border of the medial head of the clavicle) was parallel to the subclavian vein catheter in bedside chest roentgenograms (anteroposterior view), prompted us to use this subclavian approach. After supine positioning of the patient with the arm alongside the body and the left shoulder elevated 10 to 15 degrees, the puncture point was selected 1.5 cm away from the point where the coracoclavicular line crossed inferior border of the clavicle on the skin. ⋯ In 205 attempts in adult patients, 95.6% patients had successful cannulation in first attempt without significant complication. This technique appears to be promising as it is based on observation and is guided by constant landmarks and precise direction.
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In spite of modern cardiac surgical techniques, severe cardiogenic shock not responding to pharmacologic therapy and intraaortic balloon pumping develops in about 0.2% to 1.2% of patients undergoing cardiac operations. ⋯ The results justify the use of Thoratec assist device in patients with severe preoperative cardiogenic shock.
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Postcardiotomy cardiogenic shock remains a challenging situation. Many devices can be used although none of them directly unload the left ventricle except for the Hemopump. We report our clinical experience with the Hemopump 31 or sternotomy Hemopump. ⋯ Factors showing adverse effect are biventricular failure, vasoconstrictor requirement, and delayed insertion. We believe the Hemopump is a more efficient device than the intraaortic balloon pump, and that early use after onset of heart failure achieves better results.
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New volume requirements for coronary artery bypass grafting are being imposed on cardiac surgeons by hospitals, managed care groups, and others. The rationale for this is unclear. The available literature as well as additional sources relating volume and outcomes in cardiac surgery were extensively reviewed and reexamined. ⋯ Each cardiothoracic surgeon should participate in a national database that permits comparison of his or her outcomes on a risk-adjusted basis with other surgeons. Until conclusive data become available that link volume to outcome, volume should not be used as a criterion for credentialing of cardiac surgeons by hospitals, managed care groups, or others. Instead, each surgeon should be evaluated on his or her individual results.
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Right-sided circulatory failure remains a significant source of morbidity and mortality for both cardiac transplant and left ventricular assist device recipients. ⋯ Right ventricular assist devices work most effectively if implanted early enough to avoid significant, potentially irreversible end-organ injury. We liberally employ continuous arteriovenous hemodialysis, minimize the use of heparin immediately postoperatively, keep patients sedated, and continue RVAD support until the patient displays signs of hemodynamic and end-organ recovery as heralded by (1) a decrease in central venous pressure and, more importantly, a decrease in pulmonary artery diastolic pressure, (2) an increase in urine output, and (3) a decrease in serum transaminase levels.