A comparison of activated coagulation time-based techniques for anticoagulation during cardiac surgery with cardiopulmonary bypass.

OBJECTIVE: The inadequacy of heparinization during cardiopulmonary bypass (CPB) can lead to hemostatic activation with increases in postoperative blood loss and blood product requirements after cardiac surgery. Because activated coagulation time (ACT) measurements may not be accurate during CPB, the use of a heparin management system (HMS) has been advocated. This study compared the efficacy of a modified ACT-based system versus an HMS (Hepcon; Medtronic Inc, Minneapolis, MN) for CPB anticoagulation. DESIGN: Randomized controlled trial. SETTING: Regional cardiac surgery center. PARTICIPANTS: Adult elective cardiac surgical patients. INTERVENTIONS: Patients allocated to the HMS group (HC) received individualized heparin doses as indicated by the Hepcon system. Patients in the modified ACT group (C) received a standard weight-based heparin bolus with further doses as dictated by the ACT (Max-ACT, Helena Labs, Sunderland, UK). In addition, group C received supplemental heparin, independent of the ACT, as dictated by the volume of crystalloid added to the extracorporeal circuit. Outcome measures examined were hemostatic activation, postoperative chest tube loss, and blood product requirements. RESULTS: This study showed no significant difference in efficacy between the modified ACT and HMS heparinization strategies. Although the HC group received significantly greater amounts of heparin, this did not reduce hemostatic activation, postoperative blood loss, or transfusion requirements. CONCLUSION: ACT-based heparinization was found to be as efficacious as the Hepcon HMS system.

Cor-triatriatum sinister presenting in the adult as mitral stenosis: an analysis of factors which may be relevant in late presentation.

BACKGROUND: Cor-triatriatum sinister is a rare congenital heart defect resulting from the division of the left atrium by a fibro-muscular membrane. It is usual for patients to present in infancy and early childhood, although some cases remain undetected until adult life. As a consequence of trans-membrane flow obstruction, the clinical features often mimic mitral stenosis. At present, the reasons for late presentation are poorly understood. METHODS: A complete review of all cases of cor-triatriatum sinister published in the English literature from 1966 to date as mitral stenosis was performed. Statistical analysis was carried out to determine associations between measurements reflecting the communicating membrane fenestration area, the presence of several clinical variables and patient age at initial presentation. RESULTS: Both pulmonary capillary wedge pressure and mean pressure gradient were significantly higher in younger adults. In addition, the incidence of atrial fibrillation and mitral regurgitation was found to rise with advancing age. CONCLUSIONS: Cor-triatriatum sinister remains an uncommon form of congenital heart disease although it is being diagnosed with increasing frequency in adults due to improvements in diagnostic imaging. This diagnosis should be considered in all patients presenting with signs or symptoms of mitral stenosis.