Donald L. Bricker

Aprotinin for Primary Coronary Artery Bypass Grafting: A Multicenter Trial of Three Dose Regimens

BACKGROUND High-dose aprotinin reduces transfusion requirements in patients undergoing coronary artery bypass grafting, but the safety and effectiveness of smaller doses is unclear. Furthermore, patient selection criteria for optimal use of the drug are not well defined. METHODS Seven hundred and four first-time coronary artery bypass grafting patients were randomized to receive one of three doses of aprotinin (high, low, and pump-prime-only) or placebo. The patients were stratified as to risk of excessive bleeding. RESULTS All three aprotinin doses were highly effective in reducing bleeding and transfusion requirements. Consistent efficacy was not, however, demonstrated in the subgroup of patients at low risk for bleeding. There were no differences in mortality or the incidences of renal failure, strokes, or definite myocardial infarctions between the groups, although the pump-prime-only dose was associated with a small increase in definite, probable, or possible myocardial infarctions (p = 0.045). CONCLUSIONS Low-dose and pump-prime-only aprotinin regimens provide reductions in bleeding and transfusion requirements that are similar to those of high-dose regimens. Although safe, aprotinin is not routinely indicated for the first-time coronary artery bypass grafting patient who is at low risk for postoperative bleeding. The pump-prime-only dose is not currently recommended because of a possible association with more frequent myocardial infarctions.

Prosthetic replacement of cardiac valves

Abstract Development of caged-ball cardiac valve prostheses and subsequent experience with their use now allows effective surgical therapy for most patients with acquired valvular heart disease once they can no longer be managed satisfactorily by conventional medical therapy. When a patient reaches this stage in the course of acquired valvular disease, life expectancy without operation becomes seriously limited, and the quality of remaining life usually progresses rapidly toward total invalidism. It is within this context that results of prosthetic replacement of cardiac valves must be evaluated. Between April 1, 1962, and December 31, 1967, a total of 1,947 patients underwent prosthetic replacement of one or more cardiac valves in the Baylor University College of Medicine Affiliated Hospitals. No patient was refused valve replacement on the basis of endstage cardiac deterioration or concomitant coronary artery disease if the valve lesion was hemodynamically significant, and a large number of operations represented attempted salvage procedures. Over-all surgical mortality rate, including technical errors occurring in the developmental stage of these operations, was 17.7 per cent. As of December 31, 1967, there had been 295 late deaths, giving a cumulative mortality rate of 32.9 per cent, including all deaths from all causes, both related and unrelated to heart disease and valve replacement. Among the 1,307 surviving patients the great majority of those operated upon six months or more previously had returned to an active and meaningful life. Within the context of outlook for those patients without valve replacement, results of operation have been most gratifying.

Obstructive Lesions of the Left Ventricular Outflow Tract Surgical Treatment

Currently available diagnostic methods and surgical technics now allow accurate assessment and effective correction of the majority of lesions producing obstruction of the left ventricular outflow tract. On the basis of anatomic location these lesions can be divided into supravalvular, valvular, and subvalvular stenosis, and valvular lesions further can be subdivided into congenital and acquired categories. Temporary cardiopulmonary bypass with a pump oxygenator provides sustained support of the circulation for operation, while surgical technics employed are selected on the basis of etiology and location of the lesion. Experience gained in operations on 296 patients with obstructive lesions of the left ventricular outflow tract since 1956 now has demonstrated that these operations usually can be performed with acceptable risk and with excellent functional results.

Exteriorized primary repair of colon injuries.

Abstract Two classic approaches have been applied to the surgical management of colon injuries. One has been exteriorization of the injured segment. The other has been primary repair of the injury in selected cases. A compromise approach can be utilized when the risk of leakage is high in a primarily repaired segment of colon: exteriorization of the primarily repaired injury without colostomy. This technic has prevented the need for formal colostomy in 49 per cent of a group of thirty-seven patients who otherwise would have required colostomy. This approach appears to be a useful addition to the various procedures used for the treatment of penetrating injuries of the colon in civilian practice.

The use of valve replacement in the management of patients with acquired valvular heart disease

Abstract Successful surgical management of patients with acquired valvular heart disease usually requires total valve replacement, due to the far advanced nature of the diseased valves. Such a procedure is now possible due to development of caged-ball valve prostheses, and clinical experience with 607 patients in whom these prostheses were employed has been most gratifying. Operative mortality rate has been progressively reduced to less than 10 per cent and follow-up studies extending for three years have demonstrated dramatic clinical improvements in most instances. From these findings it is now our opinion that while no patient should be denied operation because of end stage cardiac deterioration, valve replacement ideally should be performed once a patient with acquired valvular heart disease first demonstrates evidence of decompensation or when angina or syncope develops.

Renal artery aneurysm presenting as a chest mass.

An enlarging mass in the right chest in a 25-year-old woman was found at operation to be a false aneurysm of the renal artery. Preoperative diagnosis was not made despite an extensive workup including arteriography. Successful resection was carried out via a posterolateral thoracotomy. Although vascular reconstruction was not feasible. The danger of rupture of such an aneurysm from an incisional biopsy is emphasized.