Ultra low dose aprotinin decreases blood loss and transfusion requirements in high risk two valve replacement surgery.

The efficacy of ultra-low-dose-aprotinin (ULDA) in 'high-risk' two valve replacement surgery, was evaluated in this prospective, randomized, double-blind study. Forty adult high-risk patients undergoing elective two valve replacement surgery, were included. The patients were divided into 2 groups of 20 each. In Group I, aprotinin in a dose of 1,000,000 KIU was administered from the end of anaesthesia induction to the time of sternotomy after a 1 ml of test dose. In Group II (control), 100 ml of normal saline was administered in a similar fashion. Coagulation parameters, blood loss, and amount of transfusion of blood / blood products were measured at specific intervals. The postoperative chest tube drainage in the first 24 hours was significantly less 203+/-35 ml (p<0.05) in Group I as compared with 490+/-104 ml in group II and consequently, Group I patients received significantly less (p<0.05) red cell concentrates and platelet transfusion. There was a significant decrease in the length of postoperative elective ventilation, intensive care unit (ICU) stay and direct costs involved in the hospital expenses with the use of ULDA. We conclude that ULDA is safe and effective in 'high-risk' two-valve replacement surgery to reduce postoperative bleeding, postoperative length of intubation and ICU stay; use of ULDA is associated with significant direct cost savings.

Candida tropicalis causing prosthetic valve endocarditis.

The incidence of endocarditis produced by the so-called "opportunists" as a complication of prosthetic valve surgery is progressively increasing in frequency and gradually transforming the clinical picture habitually associated with this disease. Candida endocarditis is an unusual but severe complication caused by Candida albicans or other fungal species. This case and a review of the literature indicate that Candida endocarditis treated with amphotericin B and prosthetic valve replacement may recur months after treatment, and that late recurrent Candida endocarditis, which is difficult to diagnose and treat, may be best prevented by lifelong antifungal suppressive therapy.

Biochemical Markers of Myocardial Injury during Coronary Artery Bypass Grafting with and without Cardiopulmonary Bypass.

Minimally invasive cardiac surgical techniques have been applied recently in the management of variety of cardiac lesions. Between December 1998 and February 1999, fifty patients underwent coronary artery bypass grafting (CABG) under two different techniques. In group A (twenty five patients), CABG was done under cardiopulmonary bypass (CPB) and in group B (twenty three patients), CABG was performed on a 'beating heart' without CPB. Serum concentration of cardiac specific enzymes CPZ-MB and Troponin-T were estimated in all the patients from pre-induction period to 72 hours after the bypass graft. Group A patients exhibited a significant (P<0.05) elevation in the CPK-MB and Troponin-T level as compared to group B. Our results show that the extent of myocardial damage following CABG is significantly less when the procedure is done on a 'beating heart'.

Video-assisted thoracoscopic surgery for closure of patent ductus arteriosus in children.

Video-assisted thoracoscopic surgery (VATS) was recently described as an approach to clip the patent ductus arteriosus (PDA). Between May 1994 and May 1996, we performed this procedure on 34 children below 12 years of age (mean 7 years). Thirty-two had an isolated PDA and two had associated small perimembranous ventricular septal defect (VSD), diagnosed on echocardiography and colour flow mapping. None had pulmonary arterial hypertension. The procedure was successful in 33 (97%) children confirmed by absence of residual shunt on serial echocardiography. Complications in the form of pneumothorax (1) and vocal card paralysis (2) were encountered in three children. The overall hospital stay was reduced to five days. In conclusion, the technique of PDA clipping using VATS is easy to learn and highly successful with acceptable risk of complications.

Significance of exercise induced increase in the diastolic pressure as an indicator of severe coronary artery disease.

A total of 100 patients were studied for the diastolic blood pressure response to treadmill exercise testing. No change in the diastolic pressure or lowering of the pressure was considered normal response. Seventy-four patients had normal and 26 patients had abnormal diastolic blood pressure response. Forty patients underwent coronary angiography. Fifty-five per cent of the patients with normal diastolic pressure response had normal coronaries compared to 20% with abnormal response. Eleven per cent with normal response and 40% with an abnormal response had triple vessel disease whereas 10% with abnormal response had left main coronary artery disease. Exercise induced ST segment depression was almost equal in both groups. Hence it can be concluded that abnormal diastolic pressure response to treadmill exercise testing is a fairly good indicator of coronary artery disease irrespective of ST segment changes.

Significance of exercise induced increase in diastolic pressure as an indicator of severe coronary artery disease.

A total of 100 patients were studied for the diastolic blood pressure response to treadmill exercise testing. No change in the diastolic pressure or lowering of the pressure was considered normal response. Seventy four patients had normal and 26 patients had abnormal diastolic blood pressure response. Out of these, 40 patients underwent coronary angiography. Fifty five percent of the patients with normal diastolic pressure response had normal coronaries compared to 20% with abnormal response (p < 0.03). Fifteen percent with normal response had triple vessel disease or left main coronary artery disease whereas forty percent with an abnormal response had significant disease (p < 0.03). Exercise induced ST segment depression was almost equal in both groups. Hence we can conclude that abnormal diastolic pressure response to treadmill exercise testing is a fairly good indicator of coronary artery disease irrespective of ST segment changes.