The Journal of thoracic and cardiovascular surgery
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J. Thorac. Cardiovasc. Surg. · Feb 1993
Late results of valve replacement with the Björk-Shiley valve (1973 to 1982)
Cardiac valve replacement with use of only the Björk-Shiley prosthesis was performed in 1253 patients between January 1973 and December 1982. There were 828 patients having aortic valve replacement, 280 patients having mitral valve replacement, and 145 patients having double valve replacement with aortic and mitral valve prostheses. Patient outcome was stratified according to multiple variables, including valve position and valve model (spherical versus convexo-concave discs). ⋯ Overall event-free survival (freedom from death, thromboembolism, anticoagulant-related bleeding, endocarditis, and reoperation) was similar for the three patient groups. Performance of the Björk-Shiley valve as judged by late patient follow-up is similar to other mechanical valves, and modifications in disc design do not appear to have reduced the threat of late valve thrombosis and thromboemboli. Evidence does not support elective explantation of this prosthesis.
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J. Thorac. Cardiovasc. Surg. · Jan 1993
Case ReportsBiventricular repair of hypoplastic right ventricle assisted by pulsatile bidirectional cavopulmonary anastomosis.
The right ventricle in patients with severe outflow obstruction or atresia and a small tricuspid valve often remains too hypoplastic even after optimal palliation to tolerate biventricular repair with closure of the atrial septal defect. In these patients, nonpulsatile cavopulmonary (Glenn) anastomosis has traditionally facilitated biventricular repair. In 1989, Billingsley and associates reported the addition of a bidirectional cavopulmonary anastomosis to the definitive biventricular repair in patients with hypoplastic right ventricle, pulmonary atresia, and intact ventricular septum. ⋯ These complications were controlled with the addition of bidirectional cavopulmonary anastomosis 2 months later. Postoperative hemodynamic or Doppler studies in these patients revealed pulsatile flow in the entire pulmonary artery system, including the artery distal to the Glenn anastomosis. This modification of biventricular repair allows primary closure of the atrial septal defect and provides pulsatile arterial flow in the entire pulmonary artery, even when the right ventricle is significantly hypoplastic.
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J. Thorac. Cardiovasc. Surg. · Jan 1993
Comparative StudyRecovery of postischemic contractile function is depressed by antegrade warm continuous blood cardioplegia.
To assess the effectiveness of warm antegrade continuous blood cardioplegia in the setting of an acute coronary arterial occlusion, we instrumented 19 Yorkshire swine to quantitate left ventricular global, systolic, diastolic, and regional mechanics. Data were acquired before and after 10 minutes of mid-left anterior descending coronary artery occlusion followed by 60 minutes of aortic crossclamping. Cardiac arrest was induced by the antegrade infusion of 20 ml/kg of warm (37 degrees C) or cold (4 degrees C) oxygenated blood cardioplegic solution followed by either continuous warm (75 ml/min, n = 9) or intermittent cold (10 ml/kg every 20 minutes, n = 10) cardioplegic reinfusions. ⋯ Similarly, left anterior descending coronary artery regional ischemic zone contractility recovered 34.5% +/- 7.3% of control function with cold cardioplegia, whereas warm cardioplegia resulted in -11.36% +/- 7.46% functional recovery indicative of dyssynchronous contraction (p < 0.05). Diastolic compliance, calculated with an exponential end-diastolic pressure-versus-volume relationship, was not changed postischemically in either group. These data suggest that warm antegrade blood cardioplegia may potentiate acute ischemic injury and provide inadequate myocardial protection.
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J. Thorac. Cardiovasc. Surg. · Jan 1993
Effect of cardiopulmonary bypass on systemic release of neutrophil elastase and tumor necrosis factor.
Leukocyte counts, plasma neutrophil elastase, tumor necrosis factor-alpha and C-reactive protein were determined serially in 19 patients undergoing elective coronary artery surgery with cardiopulmonary bypass. Neutrophil counts (mean +/- standard deviation 3.85 +/- 1.20 x 10(9)/L preoperatively) peaked 4 hours postoperatively at 10.35 +/- 4.24 x 10(9)/L (p < 0.001) and remained significantly elevated 48 hours postoperatively at 7.80 +/- 2.70 x 10(9)/L, p < 0.05. Plasma neutrophil elastase level (187 +/- 74 ng/ml preoperatively) peaked at 698 +/- 323 ng/ml at the end of surgery (p < 0.001) and remained significantly elevated at 424 +/- 146 ng/ml 48 hours postoperatively (p < 0.01). ⋯ Oxygenation, determined by the respiratory index, was impaired at the end of operation (2.07 +/- 0.82) and remained impaired 24 hours postoperatively (2.48 +/- 0.83). Impairment of oxygenation was temporally related to elevated elastase levels, but neither peak elastase levels nor the change in elastase levels with lung reperfusion correlated significantly with the area under the respiratory index curve up to 6 hours postoperatively. This study demonstrates neutrophil elastase release during cardiopulmonary bypass but fails to show a definite role for neutrophil activation or tumor necrosis factor-alpha in the etiology of pulmonary dysfunction after cardiopulmonary bypass.