Daniel A. Goor

Fresh blood units contain large potent platelets that improve hemostasis after open heart operations

Twenty units of fresh whole blood were separated into fresh packed red blood cells (PC) and platelet-rich plasma (PRP) and were transfused to 40 patients immediately after coronary bypass grafting. Patients were preoperatively randomized to receive either PRP (group A, 20 patients) or PC (group B, 20 patients). Platelet number in the PRP group was greater, but not significantly greater, than in the PC group (7.5 +/- 3 versus 5.9 +/- 2.2 x 10(10); p = not significant). However, mean platelet volume in the PC group was significantly greater (8.75 +/- 1.1 versus 6 +/- 0.7 fL). Postoperatively, group A patients bled more than group B (566 +/- 164 versus 327 +/- 41 mL; p less than 0.01) and received more red blood cell units (2.7 +/- 1.2 versus 1.6 +/- 0.7 U; p less than 0.05) and a larger number of blood products (5.9 +/- 3.7 versus 2.6 +/- 1.2 U; p less than 0.05). Transfusion of PRP to group A increased platelet count from 128 +/- 20 to 148 +/- 110 x 10(9)/L; however, platelet functions did not improve. Administration of PC to group B increased platelet count from 139 +/- 22 to 156 +/- 23 x 10(9)/L, improved platelet aggregation (with collagen from 33% +/- 20% to 53% +/- 23%, with epinephrine from 36% +/- 24% to 51% +/- 20%; p less than 0.05), and corrected the prolonged bleeding time. The results suggest that the improved hemostasis observed after fresh whole blood administration is related to the large, potent platelets that remained in the PC and were not separated to the PRP during standard platelet concentrate preparation.

Epidural anesthesia with the Trendelenburg position for cesarean section with or without a cardiac surgical procedure in patients with severe mitral stenosis: a hemodynamic study.

The hemodynamic effects of epidural anesthesia (EA) with the Trendelenburg position were studied in seven patients with severe mitral stenosis undergoing emergency cesarean section (CS) because of hemodynamic deterioration. In six patients, the CS was immediately followed by an open mitral commissurotomy under general anesthesia, whereas in one patient, the CS was performed alone. A significant reduction in heart rate (120 +/- 5 to 83 +/- 7 beats/min; P less than 0.001) was observed after induction of EA. Mean arterial pressure (MAP) decreased (78 +/- 9 to 55 +/- 5 mm Hg; P less than 0.01) simultaneously with reduction of the pulmonary capillary wedge pressure (PCWP) (37 +/- 4 to 15 +/- 4 mm Hg, P less than 0.001) and cardiac index (CI) (2.4 +/- 0.3 to 1.8 +/- 0.32 L/min/m2; P less than 0.001). However, PCWP could be adjusted by selecting the appropriate angle of the Trendelenburg position. When the PCWP was approximately 25 mm Hg, MAP and Cl increased to 72 +/- 7 mm Hg and 3.1 +/- 0.4 L/min/m2, respectively, and a satisfactory hemodynamic state was achieved. Systemic vascular resistance decreased after induction of EA (2,250 +/- 250 to 1,750 +/- 450 dyne.s.cm-5; P less than 0.001), and remained unchanged during the perioperative period. It is concluded that the combination of epidural anesthesia with tilting of the table is a safe method for urgent CS in pregnant women with critical mitral stenosis in whom termination of pregnancy is indicated because of hemodynamic deterioration.

The operative problem of small left atrium in total anomalous pulmonary venous connection: report of 5 patients.

A moderately small left atrium is a common finding in total anomalous pulmonary venous connection (TAPVC). In most patients in whom the common pulmonary vein is anastomosed to the left atrium, the small size of this chamber does not interfere with good operative results. Recently a patient was encountered in whom the left atrium measured less than 2 cm in its greatest dimension. This atrium was too small to take an anatomosis with the common pulmonary vein. Therefore the common pulmonary vein was anastomosed primarily to the right atrium, the floor of the fossa ovalis was excised, and a pericardial conduit was constructed. Subsequently, 4 additional patients have been similarly treated. The problem of small left atrium in TAPVC is discussed.

Coronary ostial stenosis after aortic valve replacement without coronary cannulation

Abstract Coronary ostial stenosis after aortic valve replacement (AVR) was attributed to trauma inflicted to the coronary ostia during coronary cannulation for selective coronary injection of cardioplegia fluid. 1–3 This report presents 2 cases who developed coronary ostial stenosis after AVR and in whom cannulation of the coronary ostia was not performed.

Percutaneous closure of a Blalock-Taussig shunt.

The technique used in the percutaneous closure of a Blalock-Taussig shunt in a 4-year-old child is described. After selective catheterization of the subclavian artery leading to the shunt, a spring coil was inserted which completely occluded the shunt.

Calculated Preoperative Mean Left Atrial Pressure as a Guide to Volume Load at the Termination of Aortocoronary Bypass Operation

The routine use of an arbitrary fixed left atrial (LA) pressure during volume load after aortocoronary bypass operation was compared with use of an individualized postoperative target LA pressure according to a calculated preoperative LA pressure in two groups of consecutive patients. The preoperative LA pressure of each patient was calculated from the preoperative left ventricular end-diastolic pressure (LVEDP) by the formula: mean LA pressure = 1.16 x LVEDP - 8.53. Left atrial pressure, mean arterial pressure, mean right atrial pressure, and cardiac output were measured simultaneously on arrival at the intensive care unit and 60 minutes later. Cardiac index (CI) and systemic vascular resistance (SVR) were calculated from the variables already mentioned. Results indicated a significantly higher CI and significantly lower SVR in patients in whom volume load was aimed at the calculated preoperative LA pressure. It was concluded that the optimal postoperative LA pressure is specific for each patient and depends on the preoperative LVEDP.

Coronary Vein Graft Marking: A Method to Prevent Graft Twisting and Length Misjudgment

Abstract A technique is described to mark the longitudinal aspect of a saphenous vein in situ in the leg, using a silk suture inserted superficially in the perivascular connective tissue of the vein. The method prevents twisting of the vein when it is inserted in the heart and also provides the surgeon with a simple measure of real graft length.