The Journal of thoracic and cardiovascular surgery
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J. Thorac. Cardiovasc. Surg. · Apr 1993
Randomized Controlled Trial Comparative Study Clinical TrialComparison of insufflated talc under thoracoscopic guidance with standard tetracycline and bleomycin pleurodesis for control of malignant pleural effusions.
The standard palliation of malignant pleural effusions involves tube thoracostomy drainage with chemical pleurodesis. The insufflation of intrapleural talc under thoracoscopic guidance (n = 39) was evaluated against documented controls that consisted of patients (n = 85) who participated in a randomized study with tube thoracostomy drainage followed by either bleomycin or tetracycline sclerosis. Under local anesthesia, which was supplemented by intravenous sedation, patients in the talc group underwent complete pleural fluid evacuation. ⋯ The tetracycline group had successful pleurodesis in only 33% at 30 days and 47% at 90 days (p < 0.001 and p < 0.001 versus the talc group). There were only two patients in the talc group in whom pleurodesis was not successful, and both were subsequently found to have extraluminal compression of the right lower lobe bronchus, which prevented lung reexpansion. These data demonstrate that the insufflation of talc into the pleural cavity under thoracoscopic guidance is a safe and efficacious procedure in the control of malignant pleural effusions.
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J. Thorac. Cardiovasc. Surg. · Apr 1993
Comparative StudyHemostatic activation during cardiopulmonary bypass with different aprotinin dosages in pediatric patients having cardiac operations.
The effect of high-dose aprotinin treatment on hemostatic activation during cardiopulmonary bypass in pediatric patients having cardiac operations was investigated. Sixty patients weighing less than 10 kg undergoing cardiac operations for different types of congenital heart diseases were studied: 20 patients were treated with aprotinin 2 x 15,000 KIU/kg, 20 patients with 2 x 30,000 KIU/kg, and 20 patients without aprotinin treatment served as the control group. Different split products of fibrinogen and/or fibrin and the fibrinolytic activity on fibrin plates were measured to assess fibrinolytic activation. ⋯ These observations suggest an attenuation of hemostatic activation during cardiopulmonary bypass with less plasmin formation and, because of inhibition of contact activation, less thrombin generation with aprotinin treatment. Thus the thrombotic-thrombolytic equilibrium is kept more balanced after cardiopulmonary bypass. High-dose aprotinin treatment is recommended for pediatric patients undergoing cardiac operations.
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J. Thorac. Cardiovasc. Surg. · Apr 1993
Cardiac-derived thromboxane A2. An initiating mediator of reperfusion injury?
After crystalloid cardioplegic arrest, cardiac-derived thromboxane A2 may be an important initiating mediator of no-reflow and hemodynamic deterioration during reperfusion because of its potent vasoactive properties. Although previous studies have already documented the increased release of cardiac thromboxane A2 after ischemia, none have studied the effects of cardiac thromboxane A2 on hemodynamics. We therefore tested the ability of cardiac thromboxane A2 to mediate deterioration of coronary flow and functional recovery during reperfusion after global ischemia. ⋯ In relation to the group with cardioplegic solution alone, postischemic aortic flow, coronary flow, cardiac output, and stroke work were all significantly greater (p < 0.05) in the group with the receptor antagonist (aortic flow: 49.5 +/- 2.4 versus 29.4 +/- 3.3 ml/min; coronary flow; 12.4 +/- 1.2 versus 8.5 +/- 1.3 ml/min; cardiac output, 62.0 +/- 2.8 versus 38.0 +/- 4.4 ml/min; stroke work, 12.6 +/- 0.8 versus 7.1 +/- 0.8 cm H2O.ml). Overall, postischemic coronary effluent thromboxane B2 levels were greater than preischemic values (105.6 +/- 12.4 versus 69.6 +/- 9.8, p < 0.05) and treatment with the receptor antagonist did not significantly affect postischemic thromboxane B2 levels (92.0 +/- 7.3 versus 82.3 +/- 15.5, p = not significant). Neither ischemia nor treatment with the receptor antagonist significantly affected heart rate.(ABSTRACT TRUNCATED AT 400 WORDS)
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J. Thorac. Cardiovasc. Surg. · Mar 1993
Prosthetic valve endocarditis. Experience with porcine bioprostheses.
Prosthetic valve endocarditis remains an infrequent but serious complication of cardiac valvular replacement. Prosthetic valve endocarditis was diagnosed in 56 (1.8%) of 3200 patients in whom one or more porcine bioprostheses were implanted between 1975 and 1988. Of the 56 patients with prosthetic valve endocarditis, there were 40 men and 16 women, with a mean age at initial implantation of 57 years (27 to 81 years). ⋯ There was one reoperation for recurrent and residual endocarditis. There was one late death as a result of recurrent prosthetic valve endocarditis. We advocate early diagnosis and aggressive combined medical and surgical treatment before the development of hemodynamic compromise and other characteristic signs when the culprit organisms are Staphylococcus aureus, gram-negative organisms, and Candida albicans.
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J. Thorac. Cardiovasc. Surg. · Mar 1993
Selection of patients for same-day coronary bypass operations.
Between March 15, 1990, and December 31, 1991, we admitted to the Virginia Mason Hospital for isolated coronary bypass operations 175 consecutive patients with chronic, stable angina pectoris who had prior coronary arteriography. One hundred patients were admitted on the same day as their operations, and 75 patients, deemed to be at higher risk, were admitted 1 day before the operation. Postoperative progress of all patients was monitored by means of a clinical pathway form with physiologic and activity measures plotted against postoperative days. ⋯ Patients admitted selectively for same-day coronary bypass are not at risk for an increased number of complications. Although their hospital stay is reduced, the reduction of their hospital charges is minimal. Preoperative admission of patients with comorbidity requiring medical management or with physical incapacity remains justified, and admitting decisions should remain with the operating surgeon, not third parties.