Atrioventricular (AV) valve dysfunction with tricuspid regurgitation is a common finding after orthotopic heart transplantation (HTx). In 20 patients the heart transplantation was performed with bicaval anastomoses and the results were compared to the precedent 20 patients operated with the standard technique. The right atrium of the recipient was completely removed and the caval anastomoses were performed on the beating heart during reperfusion. Using an interrupted suture line, no stenoses at the venous anastomoses were seen as known from the early implantation technique in heart-lung transplantation. Due to a more stable sinus rhythm only 15% of the patients in the bicaval group needed prolonged pacing (> 30 min) versus 55% (P < 0.01) in the group with standard operation. One to 3 months after surgery the transthoracic echocardiographic evaluation of the AV valve function showed tricuspid valve regurgitation (TVR) in 20% of the patients with bicaval anastomoses versus 75% with a right atrial anastomosis (P < 0.001). Tricuspid valve regurgitation during the first 2 weeks (in 31% of recipients with bicaval and in 70% with atrial anastomoses) improved in all recipients with bicaval anastomoses and in 14% of the recipients with atrial anastomosis. The modification of the operation technique did not result in significantly longer bypass time (75 +/- 14 versus 68 +/- 14 min) and ischemia time (44 +/- 12 versus 41 +/- 9 min with local organ procurement and 111 +/- 24 versus 101 +/- 19 min with distant organ procurement). The AV valve function and the postoperative rhythm after orthotopic HTx can be improved by implanting the heart with bicaval anastomoses.
Between 1978 and 1990 emergency pulmonary embolectomy with the aid of extracorporeal circulation (ECC) was performed for massive pulmonary embolism (PE) in 44 patients (19-73 yrs; 49 +/- 15 yrs). Cardiopulmonary circulation was stable in 16/44 patients but unstable in 28/44; of the latter, 15 had undergone previous cardiopulmonary resuscitation due to cardiac arrest. Diagnosis of PE was obtained clinically in 15/44 patients, by angiography in 13/44, by echocardiography in 10/44, and by perfusion scintigraphy of the lung in 6/44 patients. There were 9/44 (20%) postoperative deaths. Early mortality was significantly higher in previously resuscitated patients (p less than 0.05). There were 2/36 (6%) late deaths. Actuarial survival was 75% after 4 yrs and 71% after 8 yrs. 77% or 35 survivors were in NYHA-class I and 23% in NYHA-class II after a mean follow-up of 4.6 yrs. Pulmonary embolectomy is indicated in patients with central PE and shock; it is advisable in patients with embolism of the main pulmonary artery or its major branches or in patients with contraindication to thrombolysis. Intraoperative insertion of a vena cava filter is recommended for prevention of recurrent embolism. Preoperative resuscitation and duration of ECC are predictors for early death.
To evaluate the thromboresistant properties of phospholipidic surface coatings mimicking the lipid surface of blood cells, we studied four different types of phospholipids bound onto PVC tubings in comparison to uncoated as well as heparin bonded controls. The samples analyzed included diacetylenic phospholipid coated as a monomeric treatment (A), diacetylenic phospholipid polymerised prior to being coated (B), and two types of polymeric phospholipids made using methacrylate containing monomers (C and D). A bovine (bodyweight 67 ± 3 kg) left heart bypass model (pump flow 3.2 ±0.1 l/min) was selected and the surfaces were exposed to the blood stream up to 360 min without systemic heparinization. Thereafter another set of samples was exposed to stagnant blood over 20 min. Besides hemodynamic, hematologic and biochemical analyses, the macroscopic appearance of 119 blood exposed surface samples was graded semiquantitatively on a scale of 0 to 10: no macroscopic deposits = grade 0, 1 spot (1 mm diameter) = grade 1, 2 spots = grade 2, 5 or more spots = grade 5, up to 10% of the surface covered with clots = grade 6, 100% covered = grade 10 (p<0.05=∗): mean grade of deposits was 0.0 ± 0.0 for segments perfused and 0.0 ± 0.0 for segments exposed to stagnant blood with surfaces exposing to the blood either heparin, phopholipid A, or phospholipid B (NS). Phospholipids C and D were graded 0.0 ± 0.0 if perfused and 0.7 ± 1.2 if exposed to stagnant blood. Uncoated PVC control tubings however were graded 0.2 ± 0.8 for segments perfused and 2.7 ± 3.0 for segments exposed to stagnat blood (p<0.05 in comparison to all surfaces coated with phospholipids or heparin if perfused and if exposed to stagnant blood). Hence phospholipidic surface coatings expose significant antithrombotic properties which out perform todays standard for tubings in clinical perfusion (uncoated PVC).
Early and late results after surgery for isolated congenital valvar aortic stenosis were evaluated in a total of 86 children under 16 years of age (mean 7.4 years). Primary procedure was always conservative. There were 7/86 (8.1%) early deaths. All infants who died after the operation were younger than 4 months of age. Among the clinical variables tested by the univariate analysis only age and duration of cardiopulmonary bypass were significant prognostic factors for early death. There were 6/67 (7.7%) valve-related late deaths. Multivariate analysis could not identify any risk factors for early and late mortality. Actuarial survival was 97% (95% CL 93-101%) after 5 years, 94% (88-100%) after 10 years, 90% (82-98%) after 15 years, and 87% (77-97%) after 20 years. A total of 22/79 (28%) early survivors had a first reoperation and 5 had a second reoperation. Long follow-up interval was the only significant factor for reoperation. Actuarial reoperation-free interval was 91% (85-98%) after 5 years, 70% (58-81%) after 10 years, and 50% (34-64%) after 15 years. Significant factors for poor valve function were long duration of follow-up, endocarditis, and young age at operation. The probability of normal valve function was 91% (84-98%) after 5 years, 67% (55-79%) after 10 years, and 54% (40-68%) after 15 years.
In the setting of prolonged perfusion, species type--bovine or porcine--has an impact on hematology profile, but not on hemolytic parameters. These findings should be taken into account when cardiopulmonary bypass components are tested.
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