Aprotinin for primary coronary artery bypass grafting: a multicenter trial of three dose regimens.

BACKGROUND: High-dose aprotinin reduces transfusion requirements in patients undergoing coronary artery bypass grafting, but the safety and effectiveness of smaller doses is unclear. Furthermore, patient selection criteria for optimal use of the drug are not well defined. METHODS: Seven hundred and four first-time coronary artery bypass grafting patients were randomized to receive one of three doses of aprotinin (high, low, and pump-prime-only) or placebo. The patients were stratified as to risk of excessive bleeding. RESULTS: All three aprotinin doses were highly effective in reducing bleeding and transfusion requirements. Consistent efficacy was not, however, demonstrated in the subgroup of patients at low risk for bleeding. There were no differences in mortality or the incidences of renal failure, strokes, or definite myocardial infarctions between the groups, although the pump-prime-only dose was associated with a small increase in definite, probable, or possible myocardial infarctions (p = 0.045). CONCLUSIONS: Low-dose and pump-prime-only aprotinin regimens provide reductions in bleeding and transfusion requirements that are similar to those of high-dose regimens. Although safe, aprotinin is not routinely indicated for the first-time coronary artery bypass grafting patient who is at low risk for postoperative bleeding. The pump-prime-only dose is not currently recommended because of a possible association with more frequent myocardial infarctions.

Discussion and management of late failures in reconstructive procedures involving the abdominal aorta.

Review of fifty-eight late failures of 326 procedures performed for revascularization of the abdominal aorta over the past six years showed a low overall operative mortality of 9 per cent. Secondary vascular procedures directed at the aorta itself or at its graft substitute proved more effective in relieving symptoms and restoring flow than did secondary procedures directed at more distal problems in the lower extremities. The aortofemoral graft in conjunction with profundaplasty proved to be the most effective means of restoring flow to the lower extermity after graft occlusion in a previous aortoiliac or aortofemoral graft.

Comparison of Nissen fundoplication and Belsey Mark IV in the management of gastroesophageal reflux.

Our experience for the past four years with antireflux surgery has been reviewed. The Nissen fundoplication resulted in symptomatic improvement in 87.5 per cent of cases as compared with 64 per cent who were improved after the Belsey Mark IV procedure. Objective evaluation as measured by the standard acid reflux test (SART) revealed recurrent reflux in 9 per cent of those who underwent fundoplication and in 47 per cent of those treated with the Belsey repair. Mortality rates were similar. These results indicate that Nissen fundoplication is superior to the Belsey Mark IV procedure in the management of gastroesophageal reflux.

The asymptomatic bruit.

A review of 144 carotid endarterectomies performed in 108 patients at the Oklahoma Health Science Center over the past six years showed an acceptable operative morbidity and mortality in group of patients with an asymptomatic midcervical bruit who underwent prophylactic carotid endarterectomy prior to anticipated elective surgery. Long-term follow-up showed these patients to be free of neurologic symptoms of fatalities in 100 per cent of long-term survivors and suggests that carefully selected patients with an asymptomatic bruit may undergo carotid endarterectomy to prevent future neurologic complication.