The Annals of thoracic surgery
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Extracorporeal membrane oxygenation (ECMO) support for cardiac failure has been used in children since 1981 at the Children's Hospital in Pittsburgh. Most children required support after cardiac operations. Recently, however, a larger number of patients with decompensated cardiomyopathy or myocarditis have been supported with ECMO, which was used as a bridge to transplantation in most. ⋯ We conclude that ECMO support for severe cardiac failure is effective. Patient selection and the use of heart transplantation for intractable heart failure have improved the overall survival.
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Controversy still exists as to whether patients with previous stroke are at increased risk for neurologic complications after heart operations. ⋯ This analysis identifies a group of patients at high risk for neurologic sequelae and confirms the vulnerability of the previously injured brain to cardiopulmonary bypass, as evidenced by reappearance or exacerbation of focal deficits in such patients.
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Recent changes in health care financing have raised the specter of operation-specific, volume credentialing for cardiac surgeons. To meet this challenge, the leadership of The Society of Thoracic Surgeons formed an Ad Hoc Committee to study the question of the relationship of case volume to outcome. One product of the committee's work in this analysis of data from The Society of Thoracic Surgery National Cardiac Database. ⋯ Although the data are practice-group-specific only, there was no clinically relevant correlation of volume to outcome except at extremely low annual volume (less than 100 cases per year). Variability of outcome was significant in lower volume practices (less than 600 cases/year) and varied little at more than 600 cases per year. There were no differences in expected mortality regardless of the size of the practice.
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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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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.