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1.
Infect Control Hosp Epidemiol ; 22(8): 526-7, 2001 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-11700884

RESUMO

Gloves, worn by the surgical team to prevent transmission of infections from and to patients, are prone to tears and perforations. This study was done to determine the frequency and sites of unrecognized glove perforation during surgical procedures. The percentage of glove perforation was 14%. Of the punctures, 73% occurred in one of four contiguous locations on the glove. We recommend glove reinforcement at these locations to provide better protection, as well as to reduce the burden of double gloving.


Assuntos
Infecção Hospitalar/prevenção & controle , Luvas Cirúrgicas/normas , Salas Cirúrgicas/normas , Infecção da Ferida Cirúrgica/prevenção & controle , Desenho de Equipamento , Humanos , Cidade de Nova Iorque
2.
Heart Surg Forum ; 4(2): 113-7; discussion 117-9, 2001.
Artigo em Inglês | MEDLINE | ID: mdl-11544618

RESUMO

BACKGROUND: Increasing concern about the transmission of viral disease has generated greater interest in the use of salvaged blood as a means of alleviating the demand for homologous blood and expediting resuscitation during massive hemorrhage. Autologous blood processed by autotransfusion devices has become increasingly common in major surgery and is now largely viewed as safe and efficacious. However, there may be serious complications and sequelae associated with the use of processed blood, such as adult respiratory distress syndrome (ARDS) and renal failure. Complement cascade activation resulting from blood coming into contact with autotransfusion equipment leads to enrollment of leukocytes and release of large concentrations of cytokines, which may contribute to the development of organ failure. Our study evaluated cytokine release during cell saver (CS) blood salvage in the course of coronary artery bypass grafting (CABG) surgery. MATERIALS AND METHODS: Forty-five patients randomly selected for CABG were evaluated. All had received at least one unit of autotransfused blood by means of the Haemonetics Cell Saver System 5 (Haemonetics Corp., Braintree, MA). Each patient had four blood samples taken (pre-operative, CS container, autotransfusion from the blood bag, and one hour post-transfusion). These samples were then centrifuged and the sera were collected. An enzyme linked immunosorbent assay (ELISA) test, using the Biosource Cytoscreen solid phase "sandwich" ELISA kit (Biosource International, Camarillo, CA) was conducted to determine levels of the cytokines Interleukin (IL) 1, 2, 4, 6, 8, and 10, tumor necrosis factor (TNF), intracellular adhesion molecule (ICAM), and vascular cell adhesion molecule (VCAM). RESULTS: Significantly increased concentrations of the pro-inflammatory cytokines IL-1, 2, 4, 6, and 8, TNF, ICAM, and VCAM were noted throughout all time periods studied. The same effect was observed for the anti-inflammatory cytokine IL-10. CONCLUSION: Statistically significant increases in both the circulating levels of the pro-inflammatory and anti-inflammatory cytokines studied were recorded. It is our contention that the presence of IL-10, a down-regulator of inflammation, is responsible for attenuating the possible deleterious effects of the pro-inflammatory cytokines observed. However, morbidity and mortality, as well as the future patency of the bypass grafts, have not been correlated with the use of the autologous method of transfusion.


Assuntos
Ponte de Artéria Coronária , Citocinas/sangue , Adulto , Humanos , Molécula 1 de Adesão Intercelular/sangue , Interleucina-1/sangue , Interleucina-10/sangue , Interleucina-2/sangue , Interleucina-4/sangue , Interleucina-6/sangue , Interleucina-8/sangue , Veia Safena/cirurgia , Fator de Necrose Tumoral alfa/análise , Molécula 1 de Adesão de Célula Vascular/sangue
3.
Heart Surg Forum ; 4(2): 120-7, 2001.
Artigo em Inglês | MEDLINE | ID: mdl-11544622

RESUMO

BACKGROUND: The role of damaged endothelium in early graft occlusion has been extensively demonstrated. Seventy percent of early graft occlusions in coronary artery bypass were caused by thrombi overlying areas of endothelial loss. With the increased use of endoscopic vein harvesting, it becomes important to study the extent of endothelial damage by light and electron microscopy. In this study, we compared the degree of endothelial damage inflicted by the open and endoscopic techniques of vein harvesting using light, scanning, and transmission electron microscope. MATERIAL AND METHODS: Ninety samples of saphenous veins from 45 patients prepared for coronary artery bypass grafting (CABG) utilizing both endoscopic and standard open incision techniques were examined using light, scanning, and transmission electron microscopy. These vein samples were prepared in Plasma-lyte solution (Baxter) in combination with or without papaverine, at two distending pressures of 100 or 300 mmHg and at temperatures of either 4 degrees C or 28 degrees C in eight subgroups and one control group. The pathological alterations in the saphenous veins were graded either based on a scoring system (0 = none, 1 = < 10%, 2 = 10-25%, 3 = 25-50%, 4 = > 50%) to assess the degree of damage inflicted by these two different types of saphenectomies or by electron microscopic observed abnormalities, including endothelial cell (EC) separation, EC detachment, basement membrane (BM) exposure, collagen exposure, and EC edema. RESULTS: Using cross-tabulation and Chi-square statistical analysis, we found that the differences in the degree of endothelial damage using either of the techniques is not statistically significant (P > 0.05). CONCLUSION: Our findings indicate that endoscopic and open saphenectomies are technically comparable as far as structural damage is concerned, rendering the endoscopic technique of vein handling the preferred method for CABG.


Assuntos
Endotélio Vascular/citologia , Endotélio Vascular/lesões , Veia Safena/cirurgia , Distribuição de Qui-Quadrado , Endoscopia , Endotélio Vascular/cirurgia , Humanos , Complicações Intraoperatórias/etiologia , Microscopia Eletrônica , Veia Safena/ultraestrutura
4.
JSLS ; 5(3): 249-53, 2001.
Artigo em Inglês | MEDLINE | ID: mdl-11548832

RESUMO

BACKGROUND: Gamma interferon (IFN-gamma) is produced by activated natural killer and T cells under pathologic circumstances. The objective of our study was to compare the level of IFN-gamma in open and endoscopic methods of vein harvesting for coronary artery bypass surgery (CABG). METHOD: Ninety samples of human saphenous veins harvested from patients prepared for CABG. Pre- and post-procedure sera of the patients, in addition to supernatants of 3-day endothelial cell culture, were analyzed for IFN-gamma. RESULTS: The mean preoperative IFN-gamma level (0.09+/-0.03 pg/mL) and that for postoperative sera (0.08+/-0.02 pg/mL) were not significantly different (P = 0.2). The mean IFN-gamma level in endothelial cell culture from the endoscopic (0.18+/-0.21 pg/mL) and the open method (0.19+/-0.39 pg/mL) were not significant (P = 0.89). CONCLUSION: We recommend the endoscopic method of vein harvesting because of its lower morbidity and earlier hospital discharge.


Assuntos
Ponte de Artéria Coronária , Interferon gama/sangue , Manejo de Espécimes , Células Cultivadas , Endotélio Vascular/citologia , Humanos , Veia Safena/transplante , Procedimentos Cirúrgicos Vasculares
5.
Breast J ; 7(2): 117-9, 2001.
Artigo em Inglês | MEDLINE | ID: mdl-11328319

RESUMO

Inflammatory breast cancer is a rare but highly malignant form of breast cancer. Biopsy and histologic examination usually confirm the diagnosis. There are rare reports of difficulties in differentiating this particular type of breast malignancy from congestive heart failure (CHF). This difficulty arises when CHF is associated with unilateral breast edema and skin thickening. However, inflammatory breast carcinoma has distinctive histologic and microscopic characteristics allowing the establishment of a proper diagnosis. We report the case of a 65-year-old woman with CHF associated with unilateral breast edema and skin thickening simulating inflammatory breast carcinoma on mammography.


Assuntos
Doenças Mamárias/diagnóstico , Insuficiência Cardíaca/diagnóstico , Adenocarcinoma/diagnóstico , Idoso , Doenças Mamárias/diagnóstico por imagem , Doenças Mamárias/etiologia , Neoplasias da Mama/diagnóstico , Diagnóstico Diferencial , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico por imagem , Humanos , Radiografia
6.
JSLS ; 5(1): 37-45, 2001.
Artigo em Inglês | MEDLINE | ID: mdl-11303993

RESUMO

BACKGROUND: The use of endoscopic saphenous vein harvesting (ESVH) for coronary artery bypass grafting (CABG) is growing. This study was done to investigate the extent of endothelial injury in ESVH compared with that of the standard open method (OSVH), and under various physical and chemical preservation factors. METHODS: We endoscopically removed the saphenous vein from 45 consecutive patients undergoing saphenectomy for CABG together with a segment retrieved by the no-touch OSVH method. Vein samples from each group were divided into 8 subgroups of 5 samples each, and incubated in Plasma-Lyte solution with or without papaverine, at distending pressures of 100 or 300 mm Hg, and at either 4 degrees C or 28 degrees C, respectively. A ninth subgroup was preserved at room temperature without pressure or papaverine. The viability of cultured saphenous vein endothelial cells was assessed by counting the number of total cells and deriving the proportion of viable cells, following incubation for 72 hours. RESULTS: The median proportion of viable cells (PVC) showed a slight decline over days 0 to 4 for both harvesting methods. No significant difference existed in the median PVC between the two techniques (day 0: 75%, 72%, P = 0.8; day 1: 66.7%, 66.7%, P = 0.9; day 2: 66.7%, 66.7%, P = 0.3; day 3: 65.3%, 66.7%, P = 0.16, respectively). The mean PVC compared across temperatures of 4 degrees C, 28 degrees C, and room temperature for the ESVH was highly significant, with the highest value being for room temperature (69.5%, 56.4%, 70.3%, respectively, P = 0.0003). Results for the OSVH were not significant. The effect of distension pressure did not vary significantly for 0, 100, and 300 mm Hg for both techniques (70.3%, 63.2% and 63.4%, respectively, P = 0.46 for the ESVH; 66.5%, 68.4%, 67.4%, respectively, P = 0.94 for the OSVH). The addition of papaverine improved PCV slightly for the OSVH only (61.7%, 64.3%, respectively, P = 0.02), whereas that for the ESVH was not significant (67.3%, 72.5%, P = 0.12). CONCLUSION: The effect of ESVH on endothelial cell viability is comparable to that of the OSVH. Among the factors influencing endothelial viability during vein preparation, temperature had a major effect with lower temperatures in the range of 4 degrees C to room temperature being the most favorable one. Mechanical distension and papaverine had unimportant or inconsistent roles. We recommend the ESVH as the procedure of choice for saphenous vein harvesting due to the lower postoperative morbidity, and the lower incubation temperature needed for its better influence on potential graft patency.


Assuntos
Ponte de Artéria Coronária/métodos , Endoscopia/métodos , Endotélio Vascular/citologia , Veia Safena/transplante , Coleta de Tecidos e Órgãos/métodos , Procedimentos Cirúrgicos Vasculares/métodos , Células Cultivadas , Rejeição de Enxerto , Sobrevivência de Enxerto , Humanos , Probabilidade , Sensibilidade e Especificidade , Estatísticas não Paramétricas
7.
Heart Surg Forum ; 3(3): 241-5, 2000.
Artigo em Inglês | MEDLINE | ID: mdl-11074980

RESUMO

BACKGROUND: Numbers of intercellular and vascular cell adhesion molecules (ICAM and VCAM) and major ligands on endothelial cells for adherence of activated polymorphnuclear leukocytes, macrophages, and lymphoid cells increase in many inflammatory disorders and after trauma to different tissues. METHODS: Samples of human saphenous veins were harvested from 90 randomly selected patients who underwent coronary artery bypass graft (CABG) surgery, utilizing two different techniques (open and endoscopic). Endothelial cells were collected from the vein samples and cultured for 72 hours. Pre- and postoperative sera, in addition to the supernatants from the cultures, were analyzed for ICAM-1 and VCAM-1 using enzyme-linked immunosorbent assay. RESULTS: Mean preoperative levels of ICAM-1 and VCAM-1 (0.95 +/- 0.58 ng/mL and 1.81 +/- 1.03 ng/mL, respectively) did not differ significantly from that of postoperative sera (0.98 +/- 0.451 ng/mL and 1.74 +/- 1.05 ng/mL, respectively) (p = 0.77 and p = 0.73, respectively). Mean ICAM-1 and VCAM-1 levels in endothelial cell culture supernatants did not differ significantly between the endoscopic (0.16 +/- 0.05 ng/mL and 0.23 +/- 0.10 ng/mL, respectively) and the open method (0.18 +/- 0.08 ng/mL and 0.30 +/- 0.27 ng/mL, respectively) (p = 0.19 and 0.13, respectively). CONCLUSION: Our findings indicate that endoscopic and open saphenectomies are technically comparable in their effects on ICAM-1 and VCAM-1 synthesis during saphenous vein harvesting for CABG. We recommend the endoscopic method for its low morbidity and earlier hospital discharge.


Assuntos
Angioscopia/métodos , Ponte de Artéria Coronária/métodos , Doença das Coronárias/cirurgia , Endotélio Vascular/metabolismo , Molécula 1 de Adesão Intercelular/metabolismo , Veia Safena/transplante , Molécula 1 de Adesão de Célula Vascular/metabolismo , Biomarcadores/metabolismo , Técnicas de Cultura de Células , Endotélio Vascular/citologia , Ensaio de Imunoadsorção Enzimática , Humanos , Veia Safena/citologia , Veia Safena/metabolismo
8.
J Thorac Cardiovasc Surg ; 118(5): 857-65, 1999 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-10534691

RESUMO

OBJECTIVE: A porcine model of thoracic aortic graft infection was created, and various anatomic sites and the timing of inoculation of the graft to induce infection were investigated. Ultimately, the ability of cryopreserved allograft to resist infection was compared with that of collagen-impregnated Dacron graft. METHODS: Yorkshire pigs (n = 16) underwent placement of an expanded polytetrafluoroethylene patch graft in the ascending aorta and the left atrial appendage (phase I). Eight animals were immediately given a 50-mL bolus (1 x 10(8) cfu/mL) of Staphylococcus aureus whereas the other 8 received the infusion 24 hours later. Animals were put to death 8 weeks later and the grafts were sterilely explanted and analyzed via microbiologic culture and standard histologic procedures for evidence of infection. The results displayed that the aortic graft and a delay of induced bacteremia of 24 hours were more reliable methods of producing infection. During phase II, 13 pigs were randomized to receive either a collagen-impregnated Dacron graft (n = 6) or a cryopreserved allograft (n = 7) in the ascending aortic position only and infusion of S aureus 24 hours after the operation. The experiment then proceeded to completion. RESULTS: Phase I results displayed that use of an aortic graft and induced bacteremia 24 hours after the operation was a more reliable and reproducible method of producing infection. In phase II, graft infection was present in 38.5% (5/13) of animals, with only 16.7% (1/6) in the collagen-impregnated Dacron graft group and 57.2% (4/7) in the cryopreserved allograft group becoming infected. There was no significant difference between the collagen-impregnated Dacron graft and cryopreserved allograft groups in the incidences of thoracic aortic graft infections (P =.27, Fisher exact test). CONCLUSIONS: This novel porcine model of thoracic aortic graft infection is a reproducible method for the investigation of thoracic aortic graft infections. The phase I study investigated the timing of the induced bacteremia and the most susceptible position of a graft. Phase II demonstrated that collagen-impregnated Dacron grafts are equivalent, if not superior, to cryopreserved allografts in resisting central vascular graft infections in the ascending aorta.


Assuntos
Prótese Vascular/efeitos adversos , Infecções Relacionadas à Prótese , Animais , Aorta Torácica/cirurgia , Bacteriemia/etiologia , Colágeno , Criopreservação , Polietilenotereftalatos , Infecções Relacionadas à Prótese/etiologia , Reprodutibilidade dos Testes , Infecções Estafilocócicas/etiologia , Suínos , Fatores de Tempo , Transplante Homólogo
9.
Am Surg ; 64(4): 313-22, 1998 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-9544141

RESUMO

The finding of extraluminal gas on plain radiographs is usually associated with a perforated viscus. But, as this case shows, the finding of pneumoperitoneum is not pathogenic of a perforated viscus or even of a surgical emergency, because there are many benign explanations for a pneumoperitoneum. Perhaps the most important maneuver for differentiating between the two is by performing a through history and physical examination. This in conjunction with either a diagnostic peritoneal lavage, contrast studies, or endoscopic evaluation can help prevent a patient from having needless surgery. The causes of a nonsurgical pneumoperitoneum are described as well as a treatment plan for patients presenting with a nonsurgical pneumoperitoneum.


Assuntos
Pneumoperitônio/diagnóstico , Pneumoperitônio/etiologia , Abdome Agudo/etiologia , Algoritmos , Árvores de Decisões , Diagnóstico Diferencial , Feminino , Humanos , Anamnese , Pessoa de Meia-Idade , Seleção de Pacientes , Lavagem Peritoneal , Exame Físico , Pneumoperitônio/cirurgia , Fatores de Risco
10.
Semin Thorac Cardiovasc Surg ; 10(1): 67-71, 1998 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-9469782

RESUMO

Surgical repair of traumatic lesions or aneurysmectomy of the descending thoracic aorta necessitates the interruption of distal aortic blood flow, a situation which invariably promotes proximal hypertension accompanied by a precipitous increase in cerebrospinal fluid pressure and distal hypoperfusion. All are significant determinants of postoperative paraplegia. The institution of aortic bypass, distal to cross-clamping, by either implantation of an extraluminal passive shunt or deployment of left atrial to femoral artery (LA-FA) cannulation with a centrifugal pump, is the most widespread modality to afford a means of proximal decompression and provide distal perfusion. Passive shunt techniques do not consistently provide optimal bypass efficiency, due to inherent limitations of device design and the inability to accurately monitor and control flow. The LA-FA bypass technique is superior to passive shunts in effecting proximal unloading by allowing for precise adjustment of blood flow to equilibrate proximal and distal aortic pressures. The concomitant use of cerebrospinal fluid drainage with LA-FA bypass can effectively reduce the incidence of postoperative paraplegia. Intraoperative monitoring of evoked potentials as a sensitive indicator of spinal cord ischemia should be considered an integral component of preserving cord function. The use of cerebrospinal fluid drainage and evoked potential monitoring in conjunction with LA-FA bypass is therefore highly advisable.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Artéria Femoral , Complicações Intraoperatórias/prevenção & controle , Isquemia/prevenção & controle , Medula Espinal/irrigação sanguínea , Aorta Torácica/lesões , Circulação Extracorpórea , Átrios do Coração , Humanos , Cuidados Intraoperatórios/métodos , Paraplegia/prevenção & controle
11.
Ann Thorac Surg ; 60(5): 1255-62, 1995 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-8526609

RESUMO

BACKGROUND: Although biological glues have been used clinically in cardiovascular operations, there are no comprehensive comparative studies to help clinicians select one glue over another. In this study we determined the efficacy in controlling suture line and surface bleeding and the biophysical properties of cryoprecipitate glue, two-component fibrin sealant, and "French" glue containing gelatin-resorcinol-formaldehyde-glutaraldehyde (GRFG). METHODS: Twenty-four dogs underwent a standardized atriotomy and aortotomy; the incisions were closed with interrupted 3-0 polypropylene sutures placed 3 mm apart. All dogs had a 3- by 3-cm area of the anterior wall of the right ventricle abraded until bleeding occurred. The animals were randomly allocated into four groups: in group 1 (n = 6) bleeding from the suture lines and from the epicardium was treated with cryoprecipitate glue; in group 2 (n = 6) bleeding was treated with two-component fibrin sealant; group 3 (n = 6) was treated with GRFG glue; group 4 (n = 6) was the untreated control group. The glues were also evaluated with regard to histomorphology, tensile strength, and virology. RESULTS: The cryoprecipitate glue and the two-component fibrin sealant glue were equally effective in controlling bleeding from the aortic and atrial suture lines. Although the GRFG glue slowed bleeding significantly at both sites compared to baseline, it did not provide total control. The control group required additional sutures to control bleeding. The cryoprecipitate glue and the two-component fibrin sealant provided a satisfactory clot in 3 to 4 seconds on the epicardium, whereas the GRFG glue generated a poor clot. There were minimal adhesions in the subpericardial space in the cryoprecipitate and the two-component fibrin sealant groups, whereas moderate-to-dense adhesions were present in the GRFG glue group at 6 weeks. The two-component fibrin sealant was completely reabsorbed by 10 days, but cryoprecipitate and GRFG glues were still present. On histologic examination, both fibrin glues exhibited minimal tissue reaction; in contrast, extensive fibroblastic proliferation was caused by the GRFG glue. The two-component and GRFG glues had outstanding adhesive property; in contrast, the cryoprecipitate glue did not show any adhesive power. The GRFG glue had a significantly greater tensile strength than the two-component fibrin sealant. Random samples from both cryoprecipitate and the two-component fibrin glue were free of hepatitis and retrovirus. CONCLUSIONS: The GRFG glue should be used as a tissue reinforcer; the two-component fibrin sealer is preferable when hemostatic action must be accompanied with mechanical barrier; and finally, the cryoprecipitate glue can be used when hemostatic action is the only requirement.


Assuntos
Fator VIII/uso terapêutico , Adesivo Tecidual de Fibrina/uso terapêutico , Fibrinogênio/uso terapêutico , Formaldeído/uso terapêutico , Gelatina/uso terapêutico , Hemostáticos/uso terapêutico , Resorcinóis/uso terapêutico , Adesivos Teciduais/uso terapêutico , Animais , Procedimentos Cirúrgicos Cardíacos , Cicatriz/fisiopatologia , Cães , Combinação de Medicamentos , Avaliação Pré-Clínica de Medicamentos , Distribuição Aleatória , Técnicas de Sutura , Resistência à Tração , Fatores de Tempo , Aderências Teciduais
12.
J Card Surg ; 9(6): 631-7, 1994 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-7841643

RESUMO

Paraplegia as a consequence of spinal cord ischemia associated with procedures on the thoracic and thoracoabdominal aorta has been linked to the interaction of proximal hypertension with elevated cerebrospinal fluid pressure (CSFP) during aortic cross-clamping (AXC). CSFP reduction via cerebrospinal fluid (CSF) drainage is thought to significantly prolong the cord's tolerance to AXC. Likewise, partial exsanguination is reported to effectively reduce ischemic injury by controlling proximal hypertension. To evaluate the individual and collective efficacy of both techniques, 18 mongrel dogs (25 to 35 kg), divided into three equal groups, underwent a fourth interspace left thoracotomy AXC. Baseline proximal arterial blood pressure (PABP), distal arterial blood pressure (DABP), and CSFP were established and monitored at 5-minute intervals during 120 minutes of AXC, and for 30 minutes thereafter. Group I animals were partially exsanguinated prior to AXC to maintain PABP at a mean of 115 to 120 mmHg. Group II animals had sufficient (16 +/- 5 cc) CSF withdrawn to maintain a DABP-CSFP gradient, i.e., spinal cord perfusion pressure (SCPP) of 20 mmHg. Group III animals were treated with both CSF drainage and partial exsanguination in the same manner as groups I and II, respectively. Perioperative somatosensory evoked potential (SEP) monitoring evaluated cord function. Postoperative neurological outcome was assessed with Tarlov's criteria. SEPs degenerated approximately 22 minutes following AXC for groups II and III. In contrast, group I exhibited rapid (10 +/- 7 min) SEP loss. All five surviving group I animals displayed paralysis 48 hours postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)


Assuntos
Aorta/cirurgia , Líquido Cefalorraquidiano , Drenagem , Isquemia/prevenção & controle , Medula Espinal/irrigação sanguínea , Animais , Aorta/fisiologia , Pressão Sanguínea , Pressão do Líquido Cefalorraquidiano , Constrição , Cães , Potenciais Somatossensoriais Evocados , Complicações Intraoperatórias/prevenção & controle
13.
Cardiovasc Surg ; 2(2): 266-9, 1994 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-8049959

RESUMO

A total of 1780 patients without symptoms of cerebral ischemia undergoing coronary artery bypass grafting (CABG) were screened before surgery for carotid stenosis by pneumophlethysmography. An abnormal test was defined as a difference in ophthalmic artery pressures of > or = 5 mmHg or ophthalmic-brachial pressure index < or = 0.69. Some 99 patients (5.6%) had an abnormal ocular pneumoplethysmographic measurement (89 unilateral, ten bilateral). Of these, 26 patients underwent prophylactic carotid endarterectomy before CABG (group 1), while the remaining 73 patients had reconstruction without previous carotid endarterectomy (group 2). A total of 100 patients (group 3) with normal ocular pneumoplethysmographic results were used as controls. The three groups were comparable with respect to age, diabetes, hypertension, smoking and severity of coronary artery disease. Early (30-day) postoperative stroke rates were 0 and 4% (n = 3) for groups 1 and 2 respectively, and 0% for group 3 (P > 0.07). Early mortality rates after CABG for groups 1 and 2 were 4% (n = 1) and 1% (n = 1), respectively and 2% (n = 2) for groups 3 (P > 0.4). Late follow-up (mean 48 months) demonstrated stroke rates of 0% for group 1, and 10% and 4% for groups 2 and 3 (P > 0.08). The early mortality and stroke rates in the ten patients with bilateral abnormal ocular pneumoplethysmographic values were 0 and 0%. However, late strokes occurred significantly more often (43%) in patients with bilateral abnormal results compared with those with unilateral abnormal findings when both groups did not undergo carotid endarterectomy (P < 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)


Assuntos
Pressão Sanguínea/fisiologia , Ponte de Artéria Coronária , Artéria Oftálmica/fisiopatologia , Pletismografia/métodos , Idoso , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/cirurgia , Transtornos Cerebrovasculares/etiologia , Endarterectomia das Carótidas , Seguimentos , Previsões , Humanos , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento
14.
Ann Thorac Surg ; 54(6): 1212-3, 1992 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-1449314

RESUMO

A young woman with a history of diaphragmatic hernia presented to the hospital in respiratory distress and in premature labor. Her admission chest roentgenogram showed opacification of the left hemithorax, and her arterial blood gas analysis revealed hypoxemia. Emergency cesarean section and exploratory left thoracotomy were carried out; a large tumor occupied the left side of the chest, and pneumonectomy was performed. No diaphragmatic hernia was present. A pathologic diagnosis of primary liposarcoma was made.


Assuntos
Dispneia/etiologia , Lipossarcoma/diagnóstico por imagem , Trabalho de Parto Prematuro/etiologia , Neoplasias Pleurais/diagnóstico por imagem , Complicações Neoplásicas na Gravidez/diagnóstico por imagem , Adulto , Gasometria , Cesárea , Emergências , Feminino , Humanos , Lipossarcoma/complicações , Lipossarcoma/cirurgia , Trabalho de Parto Prematuro/cirurgia , Neoplasias Pleurais/complicações , Neoplasias Pleurais/cirurgia , Pneumonectomia , Gravidez , Complicações Neoplásicas na Gravidez/cirurgia , Prognóstico , Tomografia Computadorizada por Raios X
15.
J Cardiovasc Surg (Torino) ; 33(5): 554-9, 1992.
Artigo em Inglês | MEDLINE | ID: mdl-1447272

RESUMO

Internal mammary artery (IMA) bypass to the anterior descending coronary artery (ADA) was performed in 5125 patients from January 1978 to December 1990. The average age of patients was 68 years; males accounted for 68% (3485 patients) and 82% (4203) were NYHA Class III. Left ventricular function was impaired (ejection fraction < 40%) in 68% (3485 patients). The average number of additional saphenous vein graft (SVG) per patient was 2.2. Operative mortality was 1.8%. Mediastinitis occurred in 51 patients (1.0%). Reoperation for bleeding was necessary in 56 patients (1.1%). Perioperative myocardial infarction was seen in 102 patients (2.0%) and neurological complications occurred in 51 patients (1%). Repeat coronary angiography was performed in 1414 patients (28%) and demonstrated a patency rate of 96% in IMA grafts and 75% in SVG grafts (p < 0.001). Survival at 13 years was 80% from all causes and 90% when non-cardiac deaths were excluded. Recurrence of angina occurred in 768 patients (15%) and reoperation or PTCA was performed in 61 (1.2%). During the same time period, 2345 patients underwent coronary artery bypass utilizing solely SVG. Survival at 13 years was 68% from all causes and 78% when non-cardiac deaths were excluded (p < 0.001). Recurrent angina was present in 727 patients (31%) (< 0.001). This data suggests that long-term probability of cumulative survival and occlusion free survival were significantly greater and the probability of recurrent angina and reoperative CABG and death from cardiac causes were significantly less in the IMA patients and should be the conduit of choice in coronary bypass surgery.


Assuntos
Angina Pectoris/complicações , Ponte de Artéria Coronária/normas , Doença das Coronárias/cirurgia , Artéria Torácica Interna/transplante , Adulto , Idoso , Idoso de 80 Anos ou mais , Angina Pectoris/epidemiologia , Angioplastia Coronária com Balão/estatística & dados numéricos , Cateterismo Cardíaco , Causas de Morte , Angiografia Coronária , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Doença das Coronárias/complicações , Doença das Coronárias/mortalidade , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Recidiva , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Veia Safena/transplante , Índice de Gravidade de Doença , Taxa de Sobrevida , Grau de Desobstrução Vascular
16.
Ann Thorac Surg ; 50(2): 299-300, 1990 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-2383120

RESUMO

Infection with Mycobacterium tuberculosis is frequently found in patients with acquired immunodeficiency syndrome and can result in diffuse lymphadenopathy from disseminated disease. A case is presented of esophageal erosion and perforation secondary to mediastinal lymph node enlargement from Mycobacterium tuberculosis in a patient positive for human immunodeficiency virus. Emergent surgical intervention required resection of the perforated esophagus, end-cervical esophagostomy, gastrostomy, and feeding jejunostomy. Long-term prognosis is poor owing to acquired immunodeficiency syndrome, therefore, reconstruction at a later date is uncertain.


Assuntos
Síndrome da Imunodeficiência Adquirida/complicações , Perfuração Esofágica/etiologia , Tuberculose dos Linfonodos/complicações , Adulto , Perfuração Esofágica/cirurgia , Humanos , Masculino , Doenças do Mediastino/etiologia
17.
Ann Thorac Surg ; 49(1): 78-82; discussion 83, 1990 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-2297277

RESUMO

We investigated whether intravenous methylprednisolone (30 mg/kg) before 30 minutes of aortic cross-clamping and after 4 hours could enhance the effects of cerebrospinal fluid drainage on spinal cord perfusion pressure and postoperative paraplegia when proximal blood pressure was controlled with sodium nitroprusside and partial exsanguination. Dogs were randomized into three groups: group 1 (n = 6), control; group 2 (n = 7), steroids; and group 3 (n = 6), steroids with cerebrospinal fluid drainage. During aortic cross-clamping, blood pressure proximal to the clamp decreased significantly in each group compared with baseline (p less than 0.05), but did not differ among groups (group 1 = 82.2, group 2 = 82.1, group 3 = 86.6 mm Hg, p greater than 0.05). Mean distal pressure decreased from systemic values to 8.4, 8.5, and 3.7 mm Hg, respectively, after aortic cross-clamping (p less than 0.05); these values did not differ from one another (p greater than 0.05). During aortic cross-clamping, cerebrospinal fluid pressure in groups 1 and 2 did not differ significantly compared with baseline (12.2 versus 8.2, 14.2 versus 10.7 mm Hg, p greater than 0.05), whereas in group 3 the baseline cerebral spinal fluid pressure of 10.7 mm Hg decreased to 0.4 mm Hg (p less than 0.05). Spinal cord perfusion pressure in group 3 was significantly higher than in groups 1 and 2 (3.3 versus -3.9 and -5.7 mm Hg, p less than 0.05), but did not differ between groups 1 and 2 (p greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)


Assuntos
Aorta/fisiologia , Pressão do Líquido Cefalorraquidiano/fisiologia , Ferricianetos/uso terapêutico , Metilprednisolona/uso terapêutico , Nitroprussiato/uso terapêutico , Medula Espinal/fisiologia , Animais , Pressão Sanguínea/efeitos dos fármacos , Pressão do Líquido Cefalorraquidiano/efeitos dos fármacos , Constrição , Cães , Drenagem , Potenciais Somatossensoriais Evocados/efeitos dos fármacos , Metilprednisolona/administração & dosagem , Paraplegia/prevenção & controle , Perfusão , Pré-Medicação , Distribuição Aleatória , Medula Espinal/efeitos dos fármacos
18.
Eur J Cardiothorac Surg ; 4(4): 175-81, 1990.
Artigo em Inglês | MEDLINE | ID: mdl-2334558

RESUMO

Over the past 4-5 years, possibly with the advent of percutaneous transluminal coronary angioplasty (PTCA), there has been a changing patient population for coronary artery bypass surgery (CABS) with a gradual increase in the operative mortality. In an attempt to analyze the changing demographics in patients undergoing CABS and its effect on operative mortality, we analyzed data from 5536 consecutive patients undergoing isolated CABS. There was 4151 patients less than 70 years of age and 1385 patients greater than 70 years. Reoperative CABS procedures were performed in 385 patients, and CABS for post infarction unstable angina pectoris was performed in 578 patients. During the same time period, 2910 patients underwent PTCA. The mean age of bypass patients was 68.5 years with 38% being 70 years or older. The left ventricular ejection fraction in patients undergoing CABS averaged 38%. The average number of bypasses performed was 3.1. In comparison, patients presenting for PTCA were younger (average age 55), had normal ejection fractions (average 55%) and were predominantly treated for single or double vessel disease. The hospital mortality for elective CABS in patients less than 70 years of age was 1.8%, for reoperative CABS 3.6%, for post infarction unstable angina pectoris 4%, and for patients greater than 70 years 8%, for a combined operative mortality of 4.8%. These data suggest that because of the increasing number of elderly patients (greater than 70 years of age), and the increasing number of reoperative CABS cases and acute myocardial infarction patients with unstable angina pectoris presenting for CABS, the operative mortality will continue to rise.


Assuntos
Ponte de Artéria Coronária/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Angioplastia Coronária com Balão/estatística & dados numéricos , Doença das Coronárias/epidemiologia , Doença das Coronárias/mortalidade , Doença das Coronárias/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Fatores de Tempo
19.
Ann Thorac Surg ; 48(2): 186-91, 1989 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-2788393

RESUMO

Internal mammary artery (IMA) bypass grafting to the anterior descending coronary artery was performed in 2,100 patients between January 1978 and July 1986. The average number of additional saphenous vein grafts (SVGs) per patient was 1.8. During the same period, 1,753 patients underwent coronary artery bypass grafting using an SVG (average number of grafts per patient, 3.2). The average patient age was similar: 62.3 years for IMA grafts and 64.7 years for SVGs. Men constituted two thirds of each group. Left ventricular function was impaired (ejection fraction less than 45%) in 1,071 (51%) of IMA grafts and 847 (48.3%) of SVGs. Other aggregate risk factors, ie, elevated blood pressure, diabetes mellitus, previous myocardial infarction, and congestive heart failure, were similar in each group. Operative results and postoperative mortality of the IMA and SVG patients were comparable. However, the long-term probability of cumulative survival and occlusion-free survival were significantly greater and the probability of recurrent angina and reoperative coronary artery bypass grafting were significantly less in IMA graft patients (p less than 0.015). The relative risk of occlusion in an SVG was 4 to 5 times greater than that of the IMA graft. These data indicate that a patent IMA graft to the anterior descending coronary artery protects against recurrent angina and death from cardiac-related causes, and that the IMA should be the conduit of choice.


Assuntos
Angina Pectoris/cirurgia , Anastomose de Artéria Torácica Interna-Coronária , Adulto , Idoso , Angina Pectoris/mortalidade , Cateterismo Cardíaco , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Estudos de Avaliação como Assunto , Feminino , Seguimentos , Oclusão de Enxerto Vascular/epidemiologia , Humanos , Anastomose de Artéria Torácica Interna-Coronária/efeitos adversos , Anastomose de Artéria Torácica Interna-Coronária/mortalidade , Masculino , Pessoa de Meia-Idade , Recidiva , Reoperação , Veia Safena/transplante , Volume Sistólico
20.
Ann Thorac Surg ; 47(3): 379-83, 1989 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-2930302

RESUMO

To evaluate the effects of sodium nitroprusside (SNP) on hemodynamics, cerebrospinal fluid dynamics, and neurological outcome after 30 minutes of thoracic aortic occlusion, we monitored proximal and distal blood pressure, cerebrospinal fluid pressure, spinal cord blood flow, and somatosensory evoked potentials. In group 1 (n = 6), no attempts were made to control proximal hypertension, whereas in group 2 (n = 6), proximal blood pressure was controlled with intravenous infusion of SNP. There was no significant difference in proximal or distal blood pressure or cerebrospinal fluid pressure between the two groups at baseline. During the crossclamp interval, the mean proximal aortic pressure rose from 108 +/- 21 to 146 +/- 14 mm Hg (p less than 0.001) in the control group, whereas the mean blood pressure in the SNP group was maintained at 99.8 +/- 12 mm Hg (p = not significant compared with baseline blood pressure). Mean distal aortic pressure decreased from systemic values to 23 +/- 7 mm Hg in control animals and to 11 +/- 5 mm Hg in the SNP group (p less than 0.005). In the latter group, cerebrospinal fluid pressure increased significantly from 10.6 +/- 1.9 to 20.1 +/- 5.5 mm Hg (p less than 0.005). In animals receiving SNP, spinal cord blood flow was decreased in the lower spinal cord segments and increased in the upper cord segments. When compared with controls, this difference did not reach significance.(ABSTRACT TRUNCATED AT 250 WORDS)


Assuntos
Aorta/cirurgia , Ferricianetos/uso terapêutico , Cuidados Intraoperatórios , Nitroprussiato/uso terapêutico , Paraplegia/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Medula Espinal/efeitos dos fármacos , Animais , Aorta/fisiopatologia , Pressão Sanguínea/efeitos dos fármacos , Pressão do Líquido Cefalorraquidiano/efeitos dos fármacos , Constrição , Cães , Avaliação Pré-Clínica de Medicamentos , Potenciais Somatossensoriais Evocados/efeitos dos fármacos , Nitroprussiato/efeitos adversos , Paraplegia/etiologia , Complicações Pós-Operatórias/etiologia , Fluxo Sanguíneo Regional/efeitos dos fármacos , Medula Espinal/irrigação sanguínea , Fatores de Tempo
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