Methylene blue does not neutralize heparin after cardiopulmonary bypass.

OBJECTIVE: It was hypothesized that methylene blue could neutralize heparin in patients after cardiopulmonary bypass and become an alternative to protamine. DESIGN: This was a prospective unblinded study with patients serving as their own controls. SETTING PARTICIPANTS: A single, large university hospital. This study was conducted in patients scheduled for elective aortocoronary bypass grafting. INTERVENTIONS: When heparin was to be neutralized, patients received methylene blue, 2 to 12 mg/kg, diluted in 50 mL and infused over 20 minutes. If a clot was not observed or the activated coagulation time (ACT) remained elevated, protamine, 250 mg, was administered and the ACT was repeated. MEASUREMENTS AND MAIN RESULTS: No patient demonstrated clot after methylene blue infusion. ACT did not return to preheparin values in any patient. All patients required protamine to establish hemostasis. Protamine restored the ACT to preheparin values in every patient. The one patient who received 12 mg/kg experienced severe pulmonary hypertension. CONCLUSIONS: Methylene blue does not neutralize heparin after cardiopulmonary bypass.

Prophylactic tranexamic acid decreases bleeding after cardiac operations.

Thirty-eight patients undergoing a cardiac operation randomly received either tranexamic acid, a potent inhibitor of plasminogen, or placebo in an effort to determine whether prophylactic antifibrinolytic therapy reduces chest tube drainage. Twelve-hour blood loss was 750 +/- 314 (standard deviation) ml in the placebo group and 496 +/- 228 ml in the drug group (p = 0.0057). Fibrin split products were present more frequently in patients in the placebo group (17 of 20 compared with four of 18 in the drug group; p = 0.0002). Tranexamic acid markedly decreased plasminogen availability (112 +/- 104 units in the placebo group versus 36 +/- 18 units in the drug group, p = 0.0058). Plasma fibrinogen concentrations were similar in the placebo and drug groups. Patients in the placebo group received more fresh-frozen plasma and more mediastinal shed blood than those in the drug group. No coagulation-related complication occurred in the group receiving tranexamic acid. We conclude that prophylactic tranexamic acid can be administered safely to inhibit fibrinolysis during cardiac operations, decrease postoperative bleeding, and possibly decrease the frequency of blood product transfusion.

The use of rest and exercise radionuclide ventriculography in risk stratification in patients with suspected coronary artery disease.

The study examined the value of rest and exercise radionuclide ventriculography in risk stratification in patients with suspected coronary artery disease. There were 604 patients, 474 men and 130 women, aged 55 +/- 11 years (mean +/- standard deviation). At a follow-up of 18 +/- 10 months, there were 43 hard cardiac events: 27 patients died of cardiac causes and 16 had nonfatal acute myocardial infarctions. Univariate and multivariate survival analysis of the 10 most important clinical and exercise variables identified the exercise left ventricular ejection fraction as the most important predictor of death and total cardiac events (chi 2 = 18.1 and 29.6, respectively). The exercise heart rate was a significant, independent, but much weaker predictor of cardiac death and total events (chi 2 = 8.4 and 3.9, respectively), while exercise tolerance was a significant independent predictor of cardiac death only (chi 2 = 6.4). Actuarial life table analysis showed that the risk for future cardiac events increased in stepwise fashion as the exercise ejection fraction decreased. Thus, the exercise left ventricular ejection fraction is a useful prognosticator in patients with suspected coronary artery disease. This finding has important implications in patient management.

Effects of residual coronary artery disease on results of coronary artery bypass grafting.

To assess the effects of residual coronary artery disease (non-revascularized coronary vessels) after coronary artery bypass grafting on symptoms and exercise left ventricular function, we categorized 77 patients into 3 groups according to the extent of residual coronary artery disease: group I (n = 17) had no residual coronary artery disease (residual score = 0); group II (n = 30) had light residual coronary artery disease (score of 1 to 9, mean 4.7); and group III (n = 30) had moderate residual coronary artery disease (score greater than or equal to 10, mean 23). Sixty patients were asymptomatic after coronary artery bypass grafting (14 in group I, 24 in group II, and 22 in group III), but the remaining patients had occasional angina pectoris. The resting left ventricular ejection fraction was significantly higher in group I than in the remaining 2 groups (56 +/- 18% in group I, 47 +/- 19% in group II, and 43 +/- 16% in group III, P less than 0.05). The exercise left ventricular ejection fraction was also significantly higher in group I (61 +/- 16% in group I, 51 +/- 18% in group II and 45 +/- 18% in group III, P less than 0.01). The ejection fraction response to exercise was abnormal in 5 patients in group I, 15 patients in group II, and 19 patients in group III. Thus, coronary artery bypass grafting results in symptomatic improvement, even in patients with residual coronary artery disease. The presence of residual coronary artery disease, however, may be a determinant of exercise left ventricular function in these patients.

Clinical and echocardiographic evaluation of the St. Jude cardiac valve prosthesis: follow-up of 126 patients.

One hundred twenty-six patients with a St. Jude valve prosthesis were followed up clinically and studied by combined M-mode echocardiography and phonocardiography. Fifty patients underwent aortic valve replacement, 58 underwent mitral valve replacement and 18 underwent a combination of the two. The early postoperative mortality rate was 8% for aortic, 6.9% for mitral and 6% for combined valve replacement. Follow-up ranged from 2 to 46 months (mean +/- SD 28 +/- 9). The late postoperative mortality rate was 5%; in patients who survived, improvement in New York Heart Association functional class occurred in 97%. Major thromboembolic events occurred in two patients and anticoagulation-related complications occurred in three patients. Valve-related complications occurred in 14 patients and included bacterial endocarditis (6 patients), paravalvular leak (5 patients), severe hemolysis (1 patient), thrombosis of valve (1 patient) and possible mechanical valve failure (1 patient). In 7 of these 14 patients, repeat surgery was required and 5 patients survived. Abnormal echocardiographic findings in these seven patients included a shortened aortic closure (A2) to mitral valve opening interval, increased left atrial and left ventricular size and initial diastolic rounding of the St. Jude valve motion in the patient with the thrombosed valve. It is concluded that the St. Jude valve prosthesis is associated with favorable functional results and a low complication rate for a mean follow-up period of 28 months. Combined M-mode echocardiography and phonocardiography may be useful in assessing patients with suspected complications related to the St. Jude cardiac valve.

Comparison of echocardiography and angiography in determining the cause of severe aortic regurgitation.

To assess the accuracy of echocardiography in determining the cause of aortic regurgitation M mode and cross sectional echocardiography were compared with angiography in 43 patients with predominant aortic regurgitation. Each patient had all three investigations performed during the same admission to hospital. In each instance, the cause of aortic regurgitation was confirmed at surgery or necropsy. Seventeen patients had rheumatic aortic valve disease, 13 bacterial endocarditis with a perforated or partially destroyed cusp, five a bicuspid aortic valve (four with a history of endocarditis), and eight aortic regurgitation secondary to aortic root dilatation or aneurysm. Overall sensitivity of echocardiography and aortography was 84% in determining the cause of aortic regurgitation. Thus, rheumatic valve disease and endocarditis appear to be the most common causes of severe aortic regurgitation in this hospital based population. Furthermore, echocardiography is a sensitive non-invasive technique for determining the cause of aortic regurgitation and allows differentiation of valvular from root causes of aortic regurgitation.

Rest and redistribution thallium-201 myocardial scintigraphy to predict improvement in left ventricular function after coronary arterial bypass grafting.

To examine the value of rest and redistribution thallium-201 imaging in predicting improvement in left ventricular (LV) ejection fraction (EF) after coronary artery bypass grafting (CABG), 26 patients with coronary artery disease (CAD) and abnormal LV function were studied. Nineteen patients had pathologic Q waves preoperatively. Rest and redistribution thallium-201 images and radionuclide ventriculograms were obtained before and after CABG, and the thallium scintigrams were evaluated both quantitatively and qualitatively. The patients were divided according to the preoperative thallium scintigrams into 2 groups: Group I (16 patients) had either normal resting thallium-201 images or reversible resting perfusion defects, and Group II (10 patients) had fixed resting perfusion defects. The resting EF was less than 50% preoperatively in all patients. Fourteen patients (54%) showed improvement in EF postoperatively. Three patients (2 in Group I and 1 in Group II) showed new postoperative perfusion defects, and none of the 3 showed improvement in LV function. Of the remaining 14 patients in Group I, 12 (86%) showed improvement in LV function, compared with 2 of 9 patients in Group II (p less than 0.01). Improvement in LV function was observed in 8 of the 19 patients (42%) with abnormal Q waves. Nitroglycerin intervention radionuclide ventriculograms were obtained in 20 patients before CABG. Of the 6 patients who showed improvement in LV function with nitroglycerin, 4 also showed improvement postoperatively. Postoperative improvement in LV function was also observed in 6 of the 14 patients who did not improve with nitroglycerin. Thus, rest and redistribution thallium imaging is useful in identifying patients whose LV function will improve after CABG. Normal rest thallium-201 images or reversible resting defects correctly identified 12 of 14 patients (86%) who showed improvement in LV function postoperatively. Nitroglycerin-intervention ventriculography and abnormal Q waves were less useful in this differentiation.

Pacemaker inhibition in cardiac surgery.

We described a noninvasive method of pacemaker inhibition for patients with pacemakers who are undergoing cardiac operation. It is a simple and effective way to attain complete cessation of electrical and mechanical activity of the pacemaker. Cold cardioplegic techniques are currently used to attain cardiac arrest and myocardial preservation. For patients with permanent pacemakers who require a cardiac operation, the addition of the method of pacemaker inhibition results in a decrease in the potential for myocardial injury and a quiet operative field, which facilitates the surgical techniques.

Echocardiographic and phonocardiographic assessment of the St. Jude cardiac valve prosthesis.

Forty-three consecutive patients with a St. Jude mitral, aortic, or combined prosthesis were studied by simultaneous phonocardiography and echocardiography. Twenty-eight patients had a mitral prosthesis, 20 an aortic prosthesis, and five had both. No opening click was recorded in any patient; however, a loud aortic or mitral closing click was recorded in all 43 patients. In patients with St. Jude mitral valve prosthesis, an echo-free space separated the two leaflets during diastole; seven of these also had a mid-diastolic closing and late diastolic reopening motion; two of the seven had an associated closing mid-diastolic click. A mid-diastolic rumble was recorded in six of 28 patients with St. Jude mitral valve prosthesis. In patients with a St. Jude aortic valve prosthesis, left atrium leaflet motion was recorded in 17 of 20 patients and was indistinguishable in appearance from echocardiograms obtained with various eccentric monocusp valves. In addition, we report one case of malfunction of a St. Jude mitral valve and one case of a paravalvular leak diagnosed by echophonocardiography. We concluded that the St. Jude cardiac prosthesis has variable normal phonocardiographic-echocardiographic patterns. Knowledge of these variable patterns is important in assessing patients with suspected malfunction of a St. Jude cardiac prosthesis.

Alveolar proteinosis lung lavage using partial cardiopulmonary bypass.

An adult case of pulmonary alveolar proteinosis presented with an arterial oxygen tension of 27 mmHg (3.6 kPa) while breathing air. Dangerous hypoxaemia during lung lavage was avoided by using partial cardiopulmonary bypass.

Accuracy of roentgenograms of the chest in metastases to the lungs.

The findings on roentgenographic and tomographic examination of the chest were compared in 63 instances of suspected pulmonary metastases. These were further compared with the findings at thoracotomy in 41 instances. Of the 60 patients, 30 had soft tissue or bone sarcomas and 30 had carcinomas arising from colon, ovary or breast, and it also included five with malignant melanoma. Three patients with sarcomas had more than one thoracotomy. The diagnosis of pulmonary metastases by roentgenography of the chest was correct in 60 of 63 instances. Tomograms showed more lesions in 14 of 33 instances of sarcomas and 14 of 30 instances of carcinomas. Thoracotomy revealed even more lesions than were detected by tomography in 21 out of 26 instances with sarcomas and eight of 15 instances of carcinomas. Of the 37 patients with a solitary metastasis detected on roentgenograms of the chest, 22 were found to have additional lesions on the tomograms, 11 of 16 sarcomas and 11 of 21 carcinomas. At thoracotomy, however, nine of ten patients with a single metastasis from sarcomas were found to have even more lesions, while, in patients with carcinomas, tomograms were found to be accurate. Routinely, prior to major ablative operations for sarcomas and before excision of pulmonary metastases, it is suggested that tomography be carried out.

A clinicopathologic study of prognostic factors in cutaneous malignant melanoma.

Sex, size of the primary lesion, level of invasion at the primary site, clinical status of the regional lymph nodes at the time of diagnosis and whether or not the lymphatic or the blood vessels at the primary site were invaded by tumor cells are the prognostic factors found to influence the survival of patients with a cutaneous malignant melanoma. The last two factors were found to correlate with the level of invasion. Because of the high incidence of local recurrences after a small local excision, wide excision at the primary site of skin, subcutaneous tissue and fascia with skin graft should be the treatment of choice. The role of elective regional lymphadenectomy has to be questioned, as 51 per cent of the patients never required lymphadenectomy during the course of the disease, The higher incidence of satellitosis after such a procedure, elective lymph node dissection did not improve the survival. Therefore, it appears that regional lymph node dissection has a prognostic, rather than a therapeutic, role. From the time of the recurrence, it is clear that patients with systemic metastasis have the poorest prognosis. On the other hand, patients in whom satellitosis developed lived longer, but this was not statistically significant when compared with the survival of patients with a local recurrence or with regional lymph node metastasis; Early diagnosis should be emphasized because the two main factors that seem to influence survival are the depth of invasion and the size of the primary lesion. Finally, because the level of invasion and the status of the lymphatics and blood vessels seem to carry a high prognostic significance, each primary lesion should be examined pathologically with regard to these factors.

Primary malignant tumors of the small intestine.

Primary malignant tumors of the small intestine are uncommon. This infrequency and possible lack of awareness can result in a late diagnosis and a poor survival time. In a period of 34 years, only 55 patients were seen at our cancer institute. The average age of the patients was 56 years, with a male predominance ratio of 2.6:1.0. Twenty-one patients had adenocarcinomas, 19 had sarcomas and 15 had carcinoids. The most common signs and symptoms were abdominal pain and obstruction of the intestine. Preoperative diagnosis was established in 12 of these patients only by roentgenologic barium examination of the small intestine. At the time of diagnosis, 34 of the patients had metastasis to regional lymph nodes or distant organs. The median and five year survival times were one year and 19 per cent, respectively. Patients with carcinoids had better survival rates than those with adenocarcinomas or sarcomas. Palliative resection did not improve survival time. However, if other therapeutic modalities also were used, it might prove beneficial. Patients with palpable abdominal masses or intestinal bleeding, or both, had a worse prognosis than did those presenting with obstruction of the intestine because these are late presenting symptoms. Therefore, recurrent abdominal pain should increase clinical suspicion, and early diagnosis by careful examination of the small intestine with barium contrast material could improve the survival time. Finally, it seemed that these tumors had a high incidence of coexisting malignant conditions, as nine of the patients in our series had a second malignant tumor.