The Annals of thoracic surgery
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Advances in myocardial protection have been instrumental in making cardiac surgery safer. Debate exists over the optimal medium and the optimal temperature for cardioplegia. Currently blood cardioplegia is preferred over crystalloid; the optimal temperature, however, remains controversial. ⋯ Warm blood cardioplegia represents the latest development in myocardial protection. Preliminary studies support its efficacy. Additional studies are needed to determine the ideal route of delivery and to identify any risks associated with the inherent warm cardiopulmonary bypass required.
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Guidelines for transfusion practice have had limited impact in altering physician transfusion behavior in patients undergoing cardiac operations. This may be due to a lack of consensus on the relative risks and benefits of blood in these patients who are anemic, limited access to timely data that are necessary on which to base transfusion decisions, the recognition that empiric hemoglobin/hematocrit thresholds are limited clinical indicators of the need for blood, or a combination of these. We present an overview of current transfusion and blood conservation practices in this setting, along with possible approaches to guide the decision-making process by coupling the use of transfusion algorithms with point of care testing to use more physiologic indicators of the need for blood transfusion.
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Review Case Reports
Traumatic tricuspid valve rupture with luxation of the heart.
Three patients are described with the combination of a luxation of the heart through a pericardial tear and traumatic rupture of the papillary muscle of the tricuspid valve. In only 1 patient was the dislocation of the heart suspected preoperatively. In all 3 patients operative treatment was performed with considerable delay after the accident; nevertheless, all 3 patients survived. In all cases treatment consisted of repositioning of the heart, closure of the pericardium, and valvular repair of the tricuspid valve.
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Cerebral complications represent the leading cause of morbidity after cardiac operations. With the growing awareness of their social and economic importance, increasing attention is being given to their prevention. In the coronary artery bypass population, advanced age (> or = 75 years) is associated with an 8.9% neurologic deficit rate. ⋯ Open cardiac surgical procedures, particularly in the aged population, carry a significant increased risk of adverse neurologic outcome. Postoperative arrhythmias may result in embolic neurologic deficit. A further understanding of risk factors for cerebral injury will be of value in developing therapeutic approaches to this major clinical problem.
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Cardiac surgical patients face the threat of neurologic complications in all phases of their disease and its treatment. The incidence of preoperative transient ischemic attacks and stroke ranges from 5% to 14% and from 2% to 11%, respectively. The risk of preoperative cerebrovascular accidents is higher in patients with valvular disease than in those with coronary artery disease. ⋯ Multidimensional investigatory procedures have shown that cardiopulmonary bypass often causes cerebral dysfunction. Whether the harmful consequences are detected depends on the evaluation criteria and the investigatory methods and timing used. Further methods are needed to prevent or treat preoperative cerebrovascular accidents and particularly to improve cerebral protection during operative procedures.