Bradley J. Harlan

Failure of Antiplatelet and Anticoagulant Therapy to Improve Patency of Grafts after Coronary-Artery Bypass

Fifty patients who underwent aortocoronary saphenous-vein bypass-graft surgery were randomly assigned to one of three groups to determine the effects of antiplatelet or anticoagulant therapy on graft patency. Twenty-four patients served as controls; 13 patients received aspirin (325 mg three times a day) and dipyridamole (75 mg three times a day); and 13 patients received closely regulated warfarin therapy. Medications were begun on the third post-operative day. Six months after surgery, all patients underwent coronary angiography to assess graft patency. There were no statistically significant differences between groups in various clinical, hemodynamic and angios, 27 of 33 grafts (82 per cent) with aspirin and dipyridamole and 29 of 37 grafts (78 per cent) with warfarin (P less than 0.5), all patients had at least one patent graft. Postoperative treatment either with aspirin and dipyridamole or with warfarin failed to improve the patency of the grafts.

Early results with composite strut caged ball prostheses

The Starr-Edwards model 6400/10 mitral and 2400/10 aortic valve prostheses incorporate metallic tracks on the inner aspects of cloth-covered struts in an attempt to preserve the favorable thromboembolic performance of cloth-covered valves while avoiding the risk of cloth wear. Two hundred severity operative survivors of mitral valve replacement with the model 6400/10 prosthesis, all on continuous anticoagulant therapy, have been followed up for a mean period of 2.3 (maximal 6) years. The late survival rate is 91 percent and the removal-free rate is 94 percent at 5 years. The rate of embolism (mean +/- standard error of the mean) is 4.6 +/- 0.9 percent per patient-year. Significant bleeding complications occurred at a rate of 1.0 +/- 0.2 percent per patient-year; there were no deaths. Two hundred forty operative survivors of aortic valve replacement with a model 2400/10 prosthesis, all on continuous anticoagulant therapy, have been followed up for a mean of 2.0 (maximal 7) years. The 5 year survival rate is 84 percent and the removal-free rate is 98 percent. Embolism occurred at a rate of 3.3 +/- 0.8 percnet per patient-year. Hemorrhagic complications occurred at a rate of 2.1 +/- 0.6 percent per patient-year; there were three families. Cloth wear and hemolysis have not been significant problems with this prosthesis, and the rates of thromboembolism are comparable with those reported for xenograft bioprostheses. The composite strut (track) valve prosthesis is a durable alternative to tissue valves in patients who are able to tolerate anticoagulant therapy.

Manual of cardiac surgery

From the contents: Preoperative preparation.- Anesthesia for cardiac surgery.- Basic surgical technique.- Preparation for cardiopulmonary bypass.- Conduct of cardiopulmonary bypass.- Myocardial preservation.- Postoperative care.- Low cardiac output: pathophysiology and treatment.- Coronary artery surgery.- Left ventricular aneurysm.- Postinfarction ventricular septal defect.- Mitral valve surgery.- Aortic valve surgery.- Tricuspid valve surgery.- Patent ductus arteriosus.- Coarctation of the aorta.- Systemic pulmonary shunts.- Pulmonary valve stenosis.- Atrial septal defects.- Complete atrioventricular canal.- Ventricular septal defects.- Tetralogy of Fallot.- Transposition of the great arteries.- Total anomalous pulmonary venous connection.

Conduct of Cardiopulmonary Bypass

The first successful use of mechanically supported circulation and respiration during open cardiac surgery, by Gibbon in 1953, opened the door for the explosive growth in heart surgery that has occurred during the past four decades. Equipment and techniques for cardiopulmonary bypass are exceptionally safe, and now there is almost no risk associated with properly performed cardiopulmonary bypass. This chapter presents our basic techniques of conducting cardiopulmonary bypass and the fundamental rationale underlying the choice of these techniques.

Coarctation of the aorta

Coarctation of the thoracic aorta was first resected successfully in 1944.20 Although resection has remained the most common method of repair, additional operations have been developed to encompass the anatomic variations of coarctation. The objective of all procedures is permanent relief of any gradient across the coarctation and establishment of normal, pulsatile flow to the lower body.

Preparation for Cardiopulmonary Bypass

Sternotomy, exposure of the heart, and cannulation are usually simple and safe steps beginning an operation. However, in the case of repeat operation, they can be formidable tasks. This chapter describes our routine steps in preparation for cardiopulmonary bypass and includes techniques used for reoperation.

Systemic-Pulmonary Shunts

The dramatic performance of an anastomosis between the left subclavian artery and the left pulmonary artery by Alfred Blalock on November 29, 1944, inaugurated the age of surgical treatment of cyanotic congenital heart disease. This operation, performed in a 15-monthold girl, was strongly encouraged by Helen Taussig and was stimulated by research being carried out in Blalock’s research laboratory. In the ensuing decades, a number of additional operations have been developed to improve deficient pulmonary blood flow by constructing a communication between the systemic and pulmonary circulations.

Coronary Artery Surgery

The development of direct coronary artery surgery by Favaloro and Johnson is one of the outstanding achievements in the history of cardiac surgery. Properly performed coronary artery bypass results in immediate and predictable improvement in myocardial blood flow in the majority of patients. This increase in myocardial blood flow results in alleviation of anginal symptoms, increased exercise tolerance, freedom from medications, and overall improvement in the quality of life. In many patients coronary bypass clearly improves survival.

Aortic Valve Surgery

Surgery of the aortic valve spans all age groups and encompasses a broad spectrum of pathologic anatomy and surgical technique. In this chapter we will illustrate aortic valvotomy and replacement and briefly review surgical relief of other forms of left ventricular outflow obstruction.

Chirurgie der Trikuspidalklappe

Die Entwicklung der Trikuspidalklappenchirurgie wahrend der vergangenen 2 Jahrzehnte bewegt sich stetig vom Klappenersatz zu den konservativen klappenerhaltenden Eingriffen hin. Heute macht der Klappenersatz nur noch 5% der Eingriffe an der Trikuspidalklappe aus. Uber die konservativen klappenerhaltenden Eingriffe — Anuloplastik, gelegentlich in Verbindung mit der Kommissurotomie — bestehen, was die Indikationen zur Operation, die Wahl des plastischen Verfahrens und die technischen Details angeht, einige Gegensatzlichkeiten. In diesem Kapitel stellen wir die zwei gelaufigsten Methoden der Anuloplastik nach Carpentier und De Vega und die Kommissurotomie dar; auserdem gehen wir auf den Klappenersatz ein.