Control of heparinization by activated clotting time during bypass with improved postoperative hemostasis.

Heparin and protamine dosages monitored during open-heart operations by activated clotting time (ACT) have been reported to be superior to dosage schedules based on body weight or body surface area. To evaluate the automated ACT, 114 consecutive open-heart operations performed between October, 1974, and December, 1975, were studied. Fifty-eight operations prior to April, 1975, using a standard heparin-protamine protocol (Group I) were compared with 56 operations from April to December, 1975, monitored with an automated ACT (Group II). The two groups were similar with respect to surgical procedures, pump time, and perfusion techniques. The protamine/heparin ratio was 25% less in Group II compared with Group I, and the 12-hour postoperative blood loss was 48% less in Group II. The automated ACT is a reliable, rapid, and simple test that has resulted in improved hemostasis following cardiac operation.

Technique for using soft, flexible catheter stents in aortocoronary vein bypass operations.

A technique using soft, flexible catheter stents in performing coronary vein bypass surgery is presented which makes small vessel anastomoses easy and assures accuracy of suture placement with clear identification of the vessel lumen and an anastomosis without stenosis. It provides an essentially bloodless field without having to cross-clamp the aorta. The technique has been used to our complete satisfaction in all patients since we first started vein bypass operations in 1970. A review of the last 205 elective aortocoronary bypass grafts in 100 consecutive patients using this technique reveals a mortality of only 1% and an operative and postoperative myocardial infarction rate of 5%. About half the patients had left ventricular dysfunction with elevated end-distolic pressures, and 68% had had previous myocardial infarctions. Seventy percent of the patients are at present asymptomatic, 24% are improved, and only 4% show no improvement over their preoperative status during follow-up of one to three and one-half years.

Aortocoronary bypass in the diabetic patient.

ONe hundred twelve patients undergoing aortocoronary bypass--35 with diabetes of adult onset and 77 without diabetes--were studied to determine whether diabetic patients have additional operative risks and greater operative mortality and whether their coronary disease differs from that of nondiabetic patients. Among the diabetic patients there was a greater prevalence of preoperative unstable angina, prior myocardial infarction and class IV functional disability (New York Heart Association criteria). The major coronary arteries angiographically and at operation appeared similar in both groups. The blood flow rates measured in aortocoronary bypass vein grafts were similar in both groups, raising doubt about the presence of microvascular disease in the myocardium of the diabetic patient. Preliminary follow-up results demonstrated relief of anginal symptoms in 76 percent of diabetic and 78 percent of nondiabetic patients. The operative mortality rate of 9 percent in diabetic and 4 percent in nondiabetic patients occurred among the first 40 patients in the series; no patient in either group has died in the immediate postoperative period during the last 18 months of the study. Aortocoronary bypass should be recommended to diabetic patients with symptomatic coronary arteriosclerosis using the same criteria for operability applied to the nondiabetic population.

Surgical repair of total cleft sternum.

There are two objectives in the surgical repair of congenital total cleft sternum:(1) to afford normal bony protection to the mediastinal structures and (2) to provide stability of the anterior thorax so that respiratory function and circulation can be maintained physiologically within normal pressure relationships. A case is presented, and a new method for repair of this life-threatening congenital anomaly is described.

Rubella syndrome. Cardiovascular manifestation and surgical therapy in infants.

Of nine patients under five months of age with cardiovascular manifestations of the rubella syndrome, six had patent ductus arteriosus. Three of these six also had pulmonary artery stenosis. One infant had bilateral isolated pulmonary artery stenosis. The significant clinical findings leading to the diagnosis of pulmonary artery stenosis were axillary murmurs in the presence of right ventricular hypertrophy. Demonstration of a gradient across the stenosis at the time of catheterization, together with cineangiography, established the diagnosis. In two cases ventricular septal defect was the only cardiac anomaly.Six babies under five months of age had interruption of a patent ductus arteriosus because of uncontrollable congestive heart failure or failure to thrive. Although growth failure was not necessarily due to heart disease, all were developing satisfactorily following operation.Diagnosis and therapy of the cardiac complications of the rubella syndrome is possible in the first few months of life. Early recognition of cardiac defects in the young infant with the rubella syndrome permits aggressive medical management and in selected instances surgical therapy.