Maurice Adam

The Treatment of Postperfusion Bleeding Using ε-Aminocaproic Acid, Cryoprecipitate, Fresh-Frozen Plasma, and Protamine Sulfate

Abstract The evaluation of excessive hemorrhage was carried out in 774 patients after cardiopulmonary bypass. Excessive hemorrhage was defined in any adult patient as chest tube drainage of more than 600 ml within the first eight hours after operation. Using the prothrombin time, partial thromboplastin time, fibrinogen level, and tri-F titer tests, it was possible to differentiate medical from surgical bleeding. Hyperfibrinolytic bleeding was the most frequently identifiable coagulation disorder and occurred in 159 patients (20%). All these patients were successfully treated with Amicar (e-aminocaproic acid) alone, or with Amicar supplemented with cryoprecipitate or fresh-frozen plasma. Three patients (0.4%) were noted to have residual heparin and required additional protamine sulfate. Five patients (0.6%) had normal coagulation studies and required immediate reexploration. The overall blood consumption per patient was 2.1 units of packed cells. Whole blood and platelets were not used.

Long-Term Results with Aorta-to-Coronary Artery Bypass Vein Grafts

Abstract From our experience with more than 500 patients treated with aorta-to-coronary artery bypass vein grafts, follow-up of the first 350 patients for a period of from 6 to 43 months is analyzed. The group had 82% good results, 4% failures, 10% operative deaths, 3% late deaths, and 1% late deaths not related to the graft. Preoperative and operative factors are correlated with early and late results. The number of late deaths has not increased with the passage of time, although a distinct, moderate degradation in the quality of results in the living patients is seen. The presence of prior infarction, significant functional myocardial impairment, or extensive involvement of the coronary arterial tree tends to diminish the quality of results in survivors and to be associated with both degradation of the quality of results with the passage of time and the occurrence of late deaths.

Reoperation Following Clinical Failure of Aorta-to-Coronary Artery Bypass Vein Grafts

Abstract In the past four years the authors have used 1,360 saphenous vein grafts (SVG) in the treatment of 600 patients with coronary artery disease. In 19 patients reoperation was carried out. The SVG occlusions were related to distal obstructions or to fibrotic and inflammatory changes around the SVG and at times were unrelated to detectable causes. The presence of both closed and open vein grafts in some of the patients suggests that SVG obstructions are probably due to local causes and, it is hoped, are nonrecurring in most instances. Primary SVG failure may be related to local vein factors such as ischemic or mechanical trauma, and efforts to avoid these are strongly recommended. Of the 17 survivors, 14 had excellent results or were improved clinically following reoperation, and we have concluded that reoperation is safe and effective in achieving ultimate success in those patients in whom distal arterial runoff is adequate. Recurring angina demands prompt restudy and corrective operation when possible. Treatment of postpericardiotomy syndromes with corticoids and avoidance or evacuation of mediastinal hematomas are important.

The Evaluation of Hemorrhage in Cardiac Patients Who have Undergone Extracorporeal Circulation

The present study defines excessive bleeding in patients who undergo cardiopulmonary bypass, and evaluates the use of coagulation testing to predict those patients that bleed excessively. Evaluation of 774 consecutive patients undergoing aortocoronary bypass surgery was carried out. Cardiopulmonary bypass consisted of a bloodless prime and a Harvey bubble oxygenator. In the postoperative period, excessive hemorrhage was denned as that exceeding 600 ml chest tube drainage in the first eight hours. One hundred and sixty‐three patients (21%) were noted to be in this category. Excessive bleeding postoperatively was best predicted by a PTT greater than 45 seconds, a PT greater than 19 seconds, a fibrinogen level less than 225 mg/dl and a TFT equal to or less than 1:32. These laboratory findings occur singly or in combination. The assessment of platelet, numbers or function and fibrin(ogen) split products were of no prognostic value. Using these criteria, the re‐exploration rate for excessive hemorrhage and/or tamponade was 0.6 per cent (5 out of 774 patients). No preoperative laboratory test of hemostatic function was useful in predicting coagulopathies resulting from cardiopulmonary bypass.

The Tri-F Titer: A Rapid Test for Estimation of Plasma Fibrinogen and Detection of Fibrinolysis, Fibrin(ogen) Split Products, and Heparin

Abstract The use of extracorporeal circulation has been associated with operative and postoperative hemorrhage. In patients on the pump there are a number of different pathogenetic mechanisms that lead to hemorrhagic disorders. In essence the hemorrhagic diathesis is caused by the increased utilization or destruction of hemostatic factors, the presence of circulating anticoagulants, a reduction in hemostatic factors due to underproduction or dilution by transfused banked blood, or all three. The tri-F titer (TFT) is a new rapid and reproducible test that gives an estimate of the fibrinogen concentration and detects the presence of fibrinolysis, fibrin(ogen) split products, and circulating heparin. The use of the TFT in the diagnosis of various coagulopathies is discussed. The TFT, which depends on the formation and observation of clots in vitro, is considered to have distinct advantages over other tests which rely on immunological, solubility, and other physicochemical phenomena.

Immediate Revascularization of the Heart

The surgical treatment of myocardial ischemia demands immediate revascularization. In 70 patients this demand was met by the use of 114 aorta-to-coronary artery saphenous vein bypass grafts. Thirty-four single, 28 double, and 8 triple bypass grafts were used. They were taken to the right coronary artery (38 times), to the left anterior descending coronary artery (60 times), and to the circumflex coronary artery (16 times). There were 28 patients with three-vessel coronary disease (stenosis greater than 75%) and 15 with two-vessel disease. In spite of this, the operative mortality was only 10% (7 of 70), and four patients died of their disease while awaiting surgery. Relief of symptoms, which occurs without delay, has continued in 81% of the patients (57 of 70). The use of aorta-to-coronary artery saphenous vein bypass grafts “jump grafts” is proposed as being widely applicable, very effective, and the safest procedure available for the surgical treatment of coronary artery occlusive disease. More observations on longterm results are still needed.

Treatment of Severe Coronary Artery Disease with 5, 6, and 7 Saphenous Vein Bypasses: Review of 131 Consecutive Patients

One hundred thirty-one consecutive patients who received 5, 6, and 7 bypass grafts are analyzed. Ages ranged from 31 to 74 years. The male-to-female ratio was 7:1. As an indication of severity of disease, 25% were classified as having impending myocardial infarction and 46.6% were classified in New York Heart Association Functional Class IV. Left ventricular function was impaired in 37.4%, and 30% of the patients had left main coronary obstruction. Nonfatal perioperative myocardial infarction occurred in 4.6%. The hospital mortality was 3%. One hundred percent follow-up (5 to 55 months) revealed 4 late deaths, 3 presumably of cardiac origin. Only 7 patients in the postoperative follow-up group have complained of angina; 1 has since undergone successful reoperation.