The Annals of thoracic surgery
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Randomized Controlled Trial Comparative Study Clinical Trial
Comparison of epsilon aminocaproic acid and low-dose aprotinin in cardiopulmonary bypass: efficiency, safety and cost.
In this study we compared the clinical efficiency, safety, and economic benefit of low-dose aprotinin with epsilon aminocaproic acid (EACA) in reducing bleeding after cardiopulmonary bypass operation. ⋯ Low-dose aprotinin and EACA showed similar effects on the reduction of intraoperative and postoperative bleeding. The lower cost of EACA with no change in safety outcome suggests it is the preferred treatment.
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Clinical Trial
High early patency of saphenous vein graft for coronary artery bypass harvested with surrounding tissue.
Surgical trauma to the saphenous vein, used as a conduit for coronary artery bypass grafting, affects their occlusion rate. This study evaluates the early patency of saphenous vein grafts harvested with a pedicle of surrounding tissue that protects the vein from spasm and trauma. ⋯ Early patency rate of saphenous veins harvested with surrounding tissue is very high, even in saphenous vein grafts demonstrating low blood flow. Preservation of graft endothelium using our harvesting technique may be the explanation of this success.
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Cardiac surgery patients' hematocrits frequently fall to low levels during cardiopulmonary bypass. ⋯ Female patients and patients with smaller body surface area may be more hemodiluted than larger patients. Minimizing intraoperative anemia may result in improved outcomes for this subgroup of patients.
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As experience has grown with the use of mechanical circulatory support systems in patients with cardiogenic shock, many anecdotes have been noted where myocardial recovery occurred and devices could be removed with reasonable residual cardiovascular performance and resolution of the shock syndrome. Indeed, when first used, ventricular assist devices were inserted to bridge patients unable to be separated from cardiopulmonary bypass to eventual recovery. ⋯ There are many explanations for this, but principally, benefit is related to amelioration of circulatory insufficiency with attenuation of perturbed humoral networks and reduction of myocardial wall stress. It is important to understand how ventricular assist device implantation in select advanced heart failure patients might precipitate recovery of depressed myocardial function.
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Circulatory support devices are frequently required in postcardiotomy shock, postmyocardial infarction shock, and acute myocarditis. A panel of cardiac surgeons addressed the use of these devices in 4 patients. Cardiogenic shock after mitral valve replacement was considered best served by a left ventricular assist device (VAD) with apical rather than atrial cannulation. ⋯ Patients with severe heart failure after coronary bypass grafting were considered best served by an extracorporal membrane oxygenation (ECMO) system or a VAD. Current postcardiotomy survival rates of postcardiotomy patients of 20% to 40% are worthwhile, but can be improved. Temporary devices such as ECMO can be changed to more long-term devices when necessary.