The Annals of thoracic surgery
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Historical Article
The Society of Thoracic Surgeons: the first twenty years.
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Randomized Controlled Trial Comparative Study Clinical Trial
Hydroxyethyl starch versus albumin in cardiopulmonary bypass prime solutions.
To compare hydroxyethyl starch (HES) with 25% albumin, 20 patients undergoing aortocoronary bypass were randomized into two groups: 10 received 1,000 ml of HES and 10 received 200 ml of 25% albumin in a bloodless priming solution for cardiopulmonary bypass (CPB). Platelet aggregation, antithrombin III, reptilase time, fibrinogen, plasminogen, fluid requirements, and hemodynamics were monitored. Platelet aggregation was abnormal in both groups, being relatively poorer in the albumin group. ⋯ Postoperative weight increase and colloid requirements plus trends toward larger blood loss and blood transfusions indicate possible further evaluation. However, results suggest that HES is a safe additive to priming solutions. Compared with albumin, HES has comparable changes in coagulation variables and slightly less severe derangements in platelet aggregation.
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In an experimental study using 6 pigs, the clinical situation of accidental air embolism was mimicked by introducing a known amount of pure nitrogen into the aortic perfusion line during standard hypothermic cardiopulmonary bypass. The treatment after embolization consisted of 15 minutes of perfusion flow reversal. A special device was built to enable quantitative assessment of the amount of gas that escaped through the aortic cannula during venoarterial perfusion. ⋯ However, microscopic and histological examinations of the brain of each pig one week post-operatively did not reveal trapped gas or ischemic tissue damage. It is concluded that hyperbaric treatment after a clinical accident involving air embolism should be used if the embolus has reached the periphery before flow reversal can be effected. Since over 50% of the amount of gas introduced into the vasculature may remain behind even after prolonged venoarterial perfusion, ischemic damage of organs is still possible.
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We studied both experimentally and clinically the efficacy of partial bypass techniques in maintaining spinal cord blood flow and physiological function during surgical procedures on the thoracoabdominal aorta. We attempted to define the level of distal aortic pressure required to safely ensure normal neurological function in the absence of critical intercostal occlusion. Six dogs underwent left thoracotomy with baseline measurements of spinal cord blood flow and spinal cord impulse conduction (somatosensory evoked potentials). ⋯ We conclude that maintenance of a distal aortic pressure greater than 60 to 70 mm Hg will uniformly preserve spinal cord blood flow in the absence of critical intercostal exclusion. Should distal aortic pressure be inadequate, early reversible changes in the somatosensory evoked potential will alert the surgeon. Failure to institute measures to reverse these changes may result in paraplegia.
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Case Reports
Right ventricular outflow obstruction secondary to right-sided tamponade following myocardial trauma.
A case of isolated tamponade of the right side of the heart, seen as an abrupt change in the cardiac silhouette and as right ventricular outflow obstruction following myocardial trauma, is presented, along with a review of the English-language literature on delayed postoperative tamponade and loculated pericardial effusion. The importance of a low, fixed cardiac output and nonspecific physical findings in suggesting the clinical diagnosis is emphasized. The absence of many of the classic signs and symptoms of pericardial tamponade is noted, as is the possibility of unusual changes in the appearance or function of the heart in the presence of a loculated effusion. Finally, the differential diagnosis and the results of a variety of diagnostic techniques are discussed.