Systemic hypothermia is used almost universally in cardiac surgery. Since 1987, 2817 patients have had normothermic cardiopulmonary bypass (NCPB, "warm body", bladder temperature 36 degrees C) with cold blood cardioplegic arrest ("cold heart", 8 degrees-14 degrees C) during open heart surgery. No patients were denied this technique regardless of age, condition or severity of surgery. Clinical Characteristics in Patients: Age range: 16-84 years, mean 66; male/female ratio 3:1; pump time (min) 24-183, mean 91; cross-clamp time (min) 15-148, mean 68; types of surgery: coronary artery bypass (n = 2214), valvular (n = 489) and miscellaneous (aneurysms, tumors, arrhythmias, congenital, etc) (n = 114). One thousand and sixty-nine (1069) patients had urgent coronary artery bypass grafting (CABG). The ejection fraction was less than 0.40 in 843 patients (30%). The thirty-day operative mortality for the entire group was 1.7% (48/2817 patients): CABG = 1% (23/2214 patients), valvular = 3% (15/489 patients) and miscellaneous 9% (10/114 patients). Postoperative complications were: perioperative myocardial infarction (34 patients) = 1.2%, postoperative bleeding requiring reexploration (37 patients) = 1.3%, stroke (27 patients) = 1%, and mediastinal infection (21 patients) = 0.7%. During NCPB (WARM) systemic vascular resistance was extremely low, cardiac output was high and it was easier to wean patients from the pump. No intraaortic balloon pump was used during this period. Pulmonary complications and coagulopathy were extremely rare. These results provide reassurance that NCPB (WARM) in combination with cold cardioplegic arrest provides excellent myocardial and total body protection during cardiac surgery and is particularly suitable for high-risk patients.
Does the use of warm-body perfusion in elderly patients with severe cerebrovascular disease lead to a higher incidence of stroke, due to hypotension secondary to low systemic vascular resistance? Two thousand, three hundred eighty-three (2,383) consecutive myocardial revascularizations were performed (1987-1992) using warm-body (perfusion 37 degrees C), cold-heart surgery (cold cardioplegic arrest). The perfusion pressure was maintained between 50-70 torr; hematocrit was kept around 20%. Prospective data during hospitalization revealed 23 operative deaths (1%), and 24 patients (1%) who developed new neurological signs after surgery. The latter formed three groups: Group I consisted of six patients with severe neurological deficits, who never regained consciousness and died after support systems withdrawal. Group II included 14 patients with postoperative clinical evidence of focal cerebral infarction (9 had hemiplegia, 2 had visual disturbance, and 3 showed alteration of memory), all of whom had residual defects at discharge; Group III was composed of four patients with minor neurological deficits after surgery (hemiparesis, gait disturbance, mental changes) which had cleared up by discharge. These data were compared retrospectively with 1605 patients (1980-1986) undergoing myocardial revascularization with moderate (25-30 degrees C) hypothermia and the same surgical team and operative techniques. Both groups had similar preoperative demographics except the warm group included more elderly patients, higher numbers with unstable angina and poor ejection fraction, and more frequent use of a mammary artery conduit. Neurological complications were 1% and 1.3% for the normothermic and hypothermic perfusion groups respectively. Incremental risk factors of stroke remain: age over 70 years, diffuse atherosclerosis of the aorta, carotid occlusive disease, and severe hypotension during perfusion.(ABSTRACT TRUNCATED AT 250 WORDS)
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