The Journal of thoracic and cardiovascular surgery
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J. Thorac. Cardiovasc. Surg. · Jan 1994
Loss of endothelium-dependent vasodilatation and nitric oxide release after myocardial protection with University of Wisconsin solution.
University of Wisconsin solution has proved to be a superior form of cardioplegia for cardiac transplantation, demonstrating better functional recovery than that provided by extracellular crystalloid solutions. Furthermore, experimental data have suggested a role for University of Wisconsin solution in protection of the neonatal heart during operations for congenital heart defects. However, significant concerns have been raised regarding potential endothelial injury from the high potassium concentration contained in University of Wisconsin solution that could affect its safety and thus its clinical application. ⋯ In group 2, the vasodilatory response to bradykinin was preserved after arrest and reperfusion; 265% of baseline before arrest versus 222% of baseline after arrest. These results demonstrate a loss of endothelium-dependent vasodilatation after multidose University of Wisconsin cardioplegia caused by the inability of the endothelium to release nitric oxide. In contrast, blood cardioplegia does not result in impaired endothelial function.
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J. Thorac. Cardiovasc. Surg. · Jan 1994
Descending necrotizing mediastinitis. Advantage of mediastinal drainage with thoracotomy.
Descending necrotizing mediastinitis can occur as a complication of oropharyngeal and cervical infections that spread to the mediastinum via the cervical spaces. Delayed diagnosis and inadequate mediastinal drainage through a cervical or minor thoracic approach are the primary causes of a high published mortality rate (near 40%). Between 1985 and 1992, six men (mean age, 49 years) with descending necrotizing mediastinitis were surgically treated at our institution. ⋯ All patients underwent surgical drainage of the deep neck infection combined with mediastinal drainage through a thoracic approach. The outcome was favorable in five patients who had mediastinal drainage through a thoracotomy; the patient who had mediastinal drainage through a minor thoracic approach (anterior mediastinotomy) died of tracheal fistula on postoperative day 18. In our experience, aggressive mediastinal drainage by a thoracotomy approach regardless of the level of mediastinal involvement led to improvement in survival of these patients, with a 17% mortality rate.
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J. Thorac. Cardiovasc. Surg. · Jan 1994
Randomized Controlled Trial Clinical TrialProspective evaluation and clinical utility of on-site monitoring of coagulation in patients undergoing cardiac operation.
Although laboratory coagulation tests permit a rational approach to both diagnosis and management of coagulation disorders after cardiopulmonary bypass, their clinical utility is limited by delays in obtaining results. This study was designed to evaluate prospectively the impact of on-site coagulation testing on blood product use, operative time, and intraoperative management of microvascular bleeding. Patients who underwent cardiac procedures involving cardiopulmonary bypass and subsequently developed microvascular bleeding were randomly assigned to receive either standard therapy (n = 36) or therapy defined by a treatment algorithm based on results from an on-site coagulation monitoring laboratory (n = 30). ⋯ Patients who underwent algorithm therapy also received fewer platelet (1.6 +/- 5.9 versus 6.4 +/- 8.2 U; p = 0.02) and red blood cell (1.9 +/- 1.7 U versus 4.1 +/- 4.1 U; p = 0.01) transfusions after the operation. Nine of 36 (25%) standard group patients received initial therapy which differed from that which would have been guided by the on-site algorithm protocol. Our findings indicate that rapid and accurate coagulation test results can guide specific therapy and optimize treatment of microvascular bleeding in patients who undergo cardiac operations.
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J. Thorac. Cardiovasc. Surg. · Jan 1994
Randomized Controlled Trial Clinical TrialAllopurinol pretreatment improves postoperative recovery and reduces lipid peroxidation in patients undergoing coronary artery bypass grafting.
In this prospective, randomized, double-blind, placebo-controlled study, the clinical, biochemical, and hemodynamic effects of xanthine oxidase inhibition in patients undergoing coronary artery bypass grafting were assessed. Allopurinol pretreatment significantly reduced the use of inotropic support after the operation (5 of 25 patients versus 13 of 25 patients, p < 0.01) and increased the rate of peripheral warming (11.4 +/- 0.85 hours versus 14.4 +/- 1 hours, p < 0.02). Twenty patients (9 in the allopurinol group and 11 in the placebo group) underwent invasive hemodynamic monitoring and intraoperative coronary sinus cannulation. ⋯ Products of lipid peroxidation (thiobarbituric acid reactive substances) increased significantly in only the placebo group, with increases being evident both in the systemic circulation (9.5 +/- 3.2 nmol/gm albumin, p < 0.007, and 24 +/- 5 nmol/gm albumin, p < 0.001, at 30 seconds and 2 minutes of reperfusion, respectively) and the coronary sinus (19.4 +/- 5.8 nmol/gm albumin, p < 0.004, and 28 +/- 4 nmol/gm albumin, p < 0.001, at 2 and 5 minutes of reperfusion, respectively. No significant difference was evident between the groups with respect to cardiac enzyme or vitamin E release. It is proposed that xanthine oxidase inhibition exerts its beneficial effects by reducing the level of free radical activity associated with reperfusion during coronary artery bypass grafting.