Efficacy and safety of aprotinin in aortocoronary bypass and valve replacement operations: a placebo-controlled randomized double-blind study.

To assess the efficacy and safety of the use of a high-dose regimen of aprotinin in routine cardiac operations, a placebo-controlled randomized double-blind study was conducted in 93 adult patients undergoing cardiopulmonary bypass. Aprotinin-treated patients (group A, n = 46) received 2 x 10(5) Kallikrein Inactivating Units (KIU) of aprotinin before incision, 2 x 10(6) KIU in the priming solution and 5 x 10(5) KIU/h during CPB. Control patients (group B, n = 47) received the same volume of normal saline. Mean postoperative blood loss in ml after six hours and in total until removal of thoracic drains decreased significantly from 752 and 1933 in controls, to 358 and 1051 in treated patients (p < 0.001). Mean total transfusion needs were 2.6 (A) and 4.8 (B) units per patient. Adverse events were evenly distributed between both groups and could not be attributed to aprotinin use. We, therefore, recommend the use of a high-dose regimen of aprotinin for routine cardiac operations despite its cost.

Effects of storage temperature and fetal calf serum on the endothelium of porcine aortic valves.

Endothelial integrity and function may be an important determinant for long-term success of allograft heart valves. To determine the optimal storage temperatures for preservation of long-term endothelial function in porcine aortic valves, different storage temperatures and times were investigated. Fresh valves were either (1) stored at 4 degrees C, with or without 10% fetal calf serum supplement, for 1, 2, 4, 7, 14, 21, or 28 days; (2) cryopreserved for 2, 4, or 8 weeks at -80 degrees C or -170 degrees C; (3) cryopreserved in long-term storage (as long as 1 year), with or without fetal calf serum, at -170 degrees C. Viability of endothelial cells was assessed through measurement of the production of prostacyclin in basal and bradykinin-stimulated conditions, during in vitro incubation of the valve cusps at 37 degrees C. Endothelial morphologic variations in valves stored at 4 degrees C were evaluated by scanning electron microscopy. With storage at 4 degrees C, after 4 days the valves already produced significantly less (p < 0.05) prostacyclin than fresh preparations in both basal (0.21 +/- 0.04 versus 3.56 +/- 0.03 ng.ml-1.cm-2) and stimulated conditions (4.17 +/- 0.36 vs 24.23 +/- 1.83). Morphologic changes could not yet be distinguished with scanning electron microscopy at that time. When the storage period was extended, the levels of prostacyclin further diminished; after 14 days, prostacyclin release could no longer be detected. In cryopreserved valves, prostacyclin production was similar for as long as 2 weeks of storage either at -80 degrees C or at -170 degrees C in basal (2.69 +/- 0.63 vs 2.93 +/- 0.51) and stimulated (16.43 +/- 3.19 vs 16.50 +/- 2.57, = 6) conditions. After 8 weeks, no prostacyclin release could be detected in valves stored at -80 degrees C. After 6 months storage at -170 degrees C, the prostacyclin production was significantly (p < 0.05) reduced compared with fresh valves; it then remained constant for as long as 1 year. The valves stored with fetal calf serum produced significantly (p < 0.05) less prostacyclin than did those without fetal calf serum. For longer cryopreserved banking, we recommend storing heart valves at -170 degrees C instead of at -80 degrees C to maintain viability of endothelial cells. Fetal calf serum would harm endothelial viability during long-term cryopreservation.

Effects of different antibiotics on the endothelium of the porcine aortic valve.

Homograft heart valves are usually sterilized by exposure to multiple-antibiotic solutions at 4 degrees C for 24 hours. Several combinations of antibiotics have been proposed and discussed in the literature, but their toxicity to cusp endothelium has not been investigated yet. We studied the endothelial cell viability of porcine aortic valves by measuring their in vitro prostacyclin (PGI2) production after being exposed to different antibiotics solutions. Porcine aortic valves were immersed for 24 hours at 4 degrees C in RPMI medium to which antibiotics (Gentamycin 80 micrograms/ml, Azlocillin 500 micrograms/ml, Cloxacillin 25 micrograms/ml, Metronidazole 100 micrograms/ml, Amphotericin B 50 micrograms/ml, GACMA) were added separately or in combination. The basal and bradykinin (10 microM) stimulated PGI2 release of these valves in the medium were measured during consecutive incubation lasting 15 minutes at 37 degrees C, using a radioimmunoassay for 6-oxo-PGF1 alpha. Valves treated with the combination of all five antibiotics produced significantly less PGI2 in basal and stimulated conditions (1.64 +/- 0.63--7.25 +/- 1.73 ng/ml x cm2, p < 0.05) than the controls (4.66 +/- 0.66--30.55 +/- 3.84 ng/ml x cm2, p < 0.001). Although all antibiotics, when studied separately at the above mentioned concentrations, tended to reduce the biosynthesis of PGI2, amphotericin B was responsible for the most pronounced decrease in its production. The toxic effect of amphotericin B was dose dependent; at a low concentration (5 micrograms/ml), which is usually enough for antifungal action, toxicity was undetectable. At 50 micrograms/ml PGI2 production was half of that found at 5 micrograms/ml, although concentrations as high as 100 micrograms/ml have been used clinically to disinfect homografts. Scanning electron microscopy (SEM) also confirmed the extensive loss of endothelium after exposure to high concentrations of amphotericin B. Our study suggests that the other four antibiotics used in the concentrations described above do not damage endothelial function; amphotericin B is also harmless if used at a concentration of 5 micrograms/ml.

Repeat male genital self-mutilation precipitated by urinary complications of prior repair.

Male genital self-mutilation is uncommon, with repeat mutilation even more rare. Our case is unique in that a urological complication of the first mutilating act (meatal stenosis) helped to precipitate the second incident. This case underscores the need not only for immediate urological and psychiatric care at the time of initial mutilation but also for close, combined followup care as well. In the majority of cases, when properly monitored, the men do not repeat the mutilating act.

Isolated coronary artery bypass grafting in patients 75 years of age and older: is age per se a contraindication?

137 patients with a mean age of 77.3 years (Group A) who underwent isolated coronary artery bypass grafting (CABG) were compared to 137 patients with a mean age of 55.6 years (Group B) who also underwent isolated CABG on the same or the adjacent day as the Group A patients. Group A patients were more commonly women, and had a significantly higher incidence of unstable angina, emergency operations, extensive coronary disease, peripheral vascular disease, and multiorgan debility. However, their left-ventricular function and the extent of revascularisation was similar to Group B patients. They also had significantly more operative mortality (7.2% vs 1.45%, p < 0.001). cardiac and non-cardiac complications, and longer hospital stay (14.2 vs 8.8 days, p < 0.001) than group B patients. At a mean follow-up of 29.8 months, no significant differences were noted in Group A versus Group B patients in terms of long-term survival (95% vs 94%), freedom from angina (82% vs 81%), cardiac readmission (10% vs 12%), or in the incidence of new myocardial infarction or new CABG. Actuarial survival at 4 years was 76.9% in Group A patients and 90.1% in Group B patients. Severe angina due to extensive coronary disease commonly makes urgent surgery unavoidable in this growing population of very old patients, but the operative mortality is modest and survivors do enjoy several years of life, remaining as free of angina, etc., as similar but younger patients.

Quality of life after heart valve replacement.

Over the last three decades, heart valve replacement has become a safe and routine surgical procedure, but replacement devices are still far from ideal. Despite improvements in materials and design, life-long anticoagulation remains mandatory for mechanical valves. The major shortcoming of the less thrombogenic bioprosthetic valves is early tissue failure. Parallel to the decrease in operative mortality after heart valve replacement, the potential quality of life for survivors has been becoming increasingly important in evaluating the late results and in selecting the appropriate device for the given patient. All factors that determine the quality of life are strongly affected by the operation due to the usually dramatic improvement both in subjective status and objective parameters postoperatively. The patient, thus, can return to normal activities, maintain self-esteem and keep normal relationships at work, in the community and at home. Psychoneurologic dysfunction was also found to decrease greatly within six months, although more than a quarter of patients were depressed preoperatively because of their disease. Overall, the experience was generally satisfying.

Salvage transvenous rapid atrial pacing to terminate atrial flutter after cardiac operations.

Atrial flutter occurring after cardiac operations normally responds well to atrial overdrive pacing through epicardial atrial pacing wires and medication. When this fails, transvenous atrial overpacing offers an attractive alternative. We performed the procedure 29 times in 25 patients. Sinus rhythm returned acutely after 25 procedures in 21 patients and persisted with medication in 20 patients at follow-up. The procedure was well tolerated by all.

Quality of life after open heart surgery 16-18 May 1991.

This is a review of papers presented at the international symposium on 'Quality of Life after Open Heart Surgery' comprising the experience in more than 20,000 patients. Early identification and operation of premorbid personalities, psychological counselling before and after the operation, explanation of true risks, an educational programme in redefinition of family roles, stressing the importance of returning to normal activity in education, employment and society, financial support through health insurance to cover the high cost of open heart surgery, and formulating socioeconomic policies which encourage returning to work yield improvement in all patient groups. Specific to valve replacement is patient participation in deciding the kind of prosthesis and improvement of anticoagulation strategies. Coronary bypass patients benefit broadly through a comprehensive rehabilitation programme. For congenital heart disease, emphasis was laid on the need to educate parents about the disease, the importance of open discussion between parents, the patient and the paediatric cardiologist, and the function of a parents' self-help group. For heart transplantation the endeavour must be to increase donor availability and to develop better immunosuppression schedules. Lastly, general awareness of patients' abilities will facilitate their social integration and improve their quality of life.

Coronary artery bypass grafting in the elderly--a review of studies on patients older than 64, 69 or 74 years.

21 studies reporting on at least 100 elderly patients were reviewed to assess the influence of patient age on outcome of isolated coronary artery bypass surgery. Elderly patients were variously defined as being older than 64, 69 or 74 years of age. They had significantly higher incidences of female sex, unstable angina, urgent surgery, extensive coronary disease, peripheral vascular disease and other risk factors, but left ventricular function was similar to younger patients. The number of grafts inserted and operation times were also similar. Operative mortality and multiorgan morbidity were significantly higher with advancing age. Late survival and relief of angina were generally good.

Improved endothelial viability of heart valves cryopreserved by a new technique.

The aim of this study was to compare different techniques of aortic valve cryopreservation by studying the viability of the endothelial cells. Viability was assessed by measuring their in vitro prostacyclin (PGI2) production under basal and stimulated conditions. Fresh and cryopreserved porcine valves were incubated at 37 degrees C in tissue culture medium and PGI2 content in the medium was measured every 15 min up to 300 min. Cryopreservation by the older procedure A included 5% fetal calf serum (FCS) in the preservation medium, a plastic box inside a freezing plastic bag, a cooling schedule approximating -2 degrees C/min, a long thawing time and few dilution steps of the cryoprotectant dimethylsulphoxide (DMSO). The newer procedure B differed from A in packaging, freezing and thawing rates and DMSO dilution. Procedure C was similar to B with the exception that FCS was omitted. Leaflets preserved by procedure A produced significantly less prostacyclin as compared to those treated according to procedures B or C. We conclude that minor differences in the cryopreservation method can become critical to endothelial functional viability.

Simultaneous right ventricular contraction and left ventricular fibrillation during cardiopulmonary bypass.

Two cases of brief left ventricular fibrillation concurrent with a beating right ventricle during cardiopulmonary bypass are described. Although no left or right ventricular dysfunction was detected postoperatively, this regional electrical heterogenicity suggests inhomogeneous myocardial protection during at least a short period of time. The precise mechanisms concerned are not clear and limited clinical and animal experimental analogies can be found in the literature.

[Coronary bypass surgery using the internal mammary artery: results and 2-year clinical follow-up in Belgian patients]. / Coronaire bypass ingreep met gebruik van de arteria mammaria interna: resultaten en klinische follow-up bij Belgische patiënten na 2 jaar.

During the years 1984-1985, 867 coronary bypass operations were performed. The internal mammary artery was used in 471 patients (54.3%). Hospital mortality was 1.3%. Complications were mainly cardiac and respiratory. In the 160 Belgian patients a clinical follow-up study was performed. Mean follow-up was 28.9 +/- 7.3 months; 80% of patients had no symptoms; 6 patients (4%) underwent recatheterization because of new symptoms. In only one patient was the mammary graft occluded. During the follow-up period 5 patients died; this represents a late mortality of 3.4%. The advantages and disadvantages of venous grafts versus bypasses using the left internal mammary artery are discussed. In coronary artery bypass grafting the internal mammary artery should be used preferentially because of its resistance to atherosclerosis and excellent long-term patency.

Cardiac arrest due to aberrant left coronary artery originating from the right sinus of Valsalva in a young girl.

We report a 14-year-old girl who sustained a syncope followed by cardiac arrest. She was kept alive for three days by full cardiocirculatory support using left and right ventricular assist devices, but subsequently died in multiple organ failure. Autopsy revealed an anomalous origin of the left coronary artery (LCA) from the right sinus of Valsalva (RSV) and a major left anterior wall infarction. A cyclo-ergometric stress test performed two years before having been negative, we discuss its value in preventing sudden death due to coronary anomalies.

Subocclusion of the left anterior descending artery following blunt chest trauma.

A 54-year-old man complained of severe angina shortly after a blunt chest trauma and coronary angiography showed an isolated subtotal occlusion of the mid-left anterior descending artery. Bypass grafting was uneventful. Posttraumatic angina or supposed myocardial contusion may be due to coronary injury for which a specific treatment can be given to limit the extent of myocardial necrosis.