The Journal of thoracic and cardiovascular surgery
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J. Thorac. Cardiovasc. Surg. · Jan 1998
Clinical TrialLeft ventricular dysfunction after open repair of simple congenital heart defects in infants and children: quantitation with the use of a conductance catheter immediately after bypass.
Quantification of myocardial injury after the simplest pediatric operations by load-independent indices of left ventricular function, using conductance and Mikro-Tip pressure catheters (Millar Instruments, Inc., Houston, Tex.) inserted through the left ventricular apex. ⋯ Load-independent indices of left ventricular function can be derived from left ventricular pressure-volume loops generated by conductance and Mikro-Tip pressure catheters during the perioperative period in infants and children undergoing cardiac operations. Incomplete myocardial protection was demonstrated by a deterioration in systolic function after even short bypass and crossclamp times.
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J. Thorac. Cardiovasc. Surg. · Jan 1998
Postoperative portable chest radiographs: optimum use in thoracic surgery.
Daily portable chest radiographs are routinely ordered in many institutions after thoracic surgery. Our purpose was to assess the efficacy and cost of this practice and to determine the optimum use of postoperative x-ray studies. ⋯ These results demonstrate that routine daily portable chest x-ray studies have a minimal impact on management. It is, in fact, nonroutine x-ray studies that more often alter management. Had routine portable chest x-ray studies, which cost $114 each in our institution, been limited to one immediately after the operation, only 133 such studies (100 routine and 33 nonroutine) would have been needed in the care of these patients. Elimination of 636 (82.7%) x-ray studies reduces the cost of care by $725 per patient ($286,000 annually). For major thoracic procedures, it is safe, efficacious, and cost effective to eliminate routine postoperative portable chest x-ray studies and order nonroutine portable studies only when clinically indicated.
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J. Thorac. Cardiovasc. Surg. · Jan 1998
Randomized Controlled Trial Clinical TrialCardiopulmonary effects of 7.2% saline solution compared with gelatin infusion in the early postoperative period after coronary artery bypass grafting.
We report a clinical study on the use of 7.2%, 2400 mOsm/L, hypertonic saline solution compared with gelatin in early postoperative period after coronary artery bypass surgery. ⋯ There were no significant demographic or operative difference between the groups. Patients receiving saline solution had a larger diuresis at 12 (p = 0.0008) and 24 hours (p = 0.002), with less positive balance at 12 hours (p = 0.0008). The group receiving saline solution had better cardiorespiratory recovery with shorter extubation time (p = 0.033), and earlier increase in cardiac index with a positive correlation between plasma sodium content and cardiac index. Maximum increase in cardiac index (+31%) occurred at 60 minutes (p = 0.025) associated with 8% increase in plasma sodium content (r = 0.51, p = 0.01), without a concomitant rise in pulmonary capillary wedge pressure. The group receiving gelatin had a linear increase in cardiac index with increasing pulmonary capillary wedge pressure, reaching +16% from baseline by 90 minutes. Compared with the gelatin-treated group, patients receiving saline solution had unchanged systemic vascular resistance index but a significantly lower pulmonary vascular resistance index with a negative correlation to plasma sodium content. There was no difference in levels of urea and creatinine. No side-effect attributable to the use of saline solution was observed.
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J. Thorac. Cardiovasc. Surg. · Jan 1998
Randomized Controlled Trial Clinical TrialOptimal flow rates for integrated cardioplegia.
Antegrade cardioplegic delivery may be impaired by coronary occlusions, whereas retrograde delivery of cardioplegic solution may be inhomogeneous, leading to an accumulation of lactate and hydrogen ions, the products of anaerobic metabolism. Integrated cardioplegia using continuous retrograde cardioplegia and antegrade infusions into completed vein grafts washes out metabolites accumulated in regions inadequately perfused by retrograde cardioplegia alone. To determine the flow rates required to achieve the greatest washout, we compared a high flow rate (200 ml/min) to a low flow rate (100 ml/min). ⋯ Tepid retrograde cardioplegia resulted in an accumulation of toxic metabolites. The addition of antegrade vein graft infusions at a flow rate of 100 ml/min resulted in a washout of these metabolites. A flow rate of 200 ml/min further improved this washout and resulted in improved ventricular function. An integrated approach to myocardial protection using a flow rate of 200 ml/min may improve the results of coronary bypass surgery.
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J. Thorac. Cardiovasc. Surg. · Jan 1998
Effect of volume reduction on lung transplant timing and selection for chronic obstructive pulmonary disease.
End-stage chronic obstructive pulmonary disease has traditionally been treated with lung transplantation. For 2 years, our lung transplantation program has placed patients with appropriate criteria for lung transplantation and volume reduction into a prospective management algorithm. These patients are offered the lung volume reduction option as a "bridge" to "extend" the eventual time to transplantation. We examine the results of this pilot program. ⋯ Lung volume reduction in these patients is safe. Seventy-seven percent of otherwise suitable candidates for lung transplantation achieved initial good results from volume reduction and were deactivated from the list (placed on status 7). Most patients entering our prospective management algorithm have either significantly delayed or completely avoided lung transplantation after volume reduction. Lung volume reduction has substantially affected the practice, timing, and selection of patients for lung transplantation. Our waiting list now has a reduced percentage of patients with a diagnosis of chronic obstructive pulmonary disease compared with 3 years ago. Our experience suggests that lung volume reduction may be limited as a "bridge" in alpha 1-antitrypsin deficiency.