The Annals of thoracic surgery
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Despite the incidence of heart disease during pregnancy falling to 1.5% over the last 25 years, when a cardiac operation is required the risk is obviously greater as two lives are at risk. The risk to the mother is now similar to that for nonpregnant female patients (3% overall) but the fetal mortality remains high (19%). Cardiac operation is ill advised except in extreme emergencies during the first two trimesters as the incidence of teratogenesis is high. ⋯ Finally, uterine contractions occur in response to bypass, possibly due to a dilutional effect from the stabilizing influence of progesterone. Various techniques to modify this include the administration of progesterone, beta2-agonists, and intravenous alcohol, all with some effect. Uterine monitoring is essential to allow early control of these contractions as they are associated with significant fetal loss.
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Isolated mitral valve injury after blunt chest trauma is a very rare event. This disruption, causing sudden and severe mitral regurgitation, will rapidly lead to congestive heart failure and death unless operatively corrected. A high index of suspicion coupled with appropriate diagnostic tests will provide the diagnosis and allow operative correction. We report a patient who survived this injury and review all previous reports of blunt traumatic disruption of the mitral valve.
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The cardiopathic patient can sustain acute heart failure during pregnancy. In such cases, if open heart operation is necessary to save the patient's life, the fetus could be seriously compromised after exposure to cardiopulmonary bypass. From 1958 to 1992, 69 reports of cardiac operations during pregnancy with the aid of cardiopulmonary bypass have been published. ⋯ Hypothermia decreases O2 exchange through the placenta. Pump flow and mean arterial pressure during cardiopulmonary bypass seem to be the most important parameters that influence fetal oxygenation. We speculate that cardiac operation is not a contraindication to pregnancy prolongation.
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Development of increasingly complex perfusion devices with bonded heparin allowed for significant improvement of thromboresistance of most basic components required for cardiopulmonary bypass. In his recent review of heparin-coated cardiopulmonary bypass circuits, Gravlee cited 91 references dealing with heparin-coated surfaces, and far more can be found if the search includes material technology or heparin-coated devices not designed for cardiopulmonary bypass (eg, ventricular assist devices, hemofilters, catheters). The present review is focused on long-term application of heparin-coated equipment in conjunction with basic work on heparin bonding relevant for extracorporeal membrane oxygenation. ⋯ However, the longest clinical application of a single device is that of an intravascular gas exchanger that remained fully functional during a 29-day implantation period. Finally, it appears, that circulating protamine interacts with surface-bound heparin. Protamine administration should therefore be avoided during perfusion with heparin-bonded equipment to maintain the improved thromboresistance.
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Cold agglutinins are commonly found in sera of healthy persons. They rarely become clinically apparent due to their activity at low temperatures. In these patients, cardiovascular operations requiring hypothermia can result in complications such as hemolysis, renal failure, and myocardial damage and can cause unexpected morbidity and mortality. ⋯ Preoperative plasmapheresis may be a useful adjunct, especially in patients requiring operation under profound hypothermia and circulatory arrest. Currently, warm heart surgery appears to be the most expedient method. Unexpected detection of agglutination during operation or hemolysis after operation requires a specific treatment plan.