Srikrishna Sirivella

Mannitol, furosemide, and dopamine infusion in postoperative renal failure complicating cardiac surgery

BACKGROUND Acute renal failure occurring in the postoperative period, requiring dialysis after cardiac surgery is an important risk factor for an early mortality, and the overall mortality of this complication is as high as 40% to 60%. Dialysis in the early postoperative period is often complicated by acute hemodynamic, metabolic, and hematologic effects that adversely affect cardiopulmonary function in patients stabilizing from recent surgery. The purpose of this study was to avoid the need for dialysis by infusion of the solution of mannitol, furosemide, and dopamine in the early postoperative period in oliguric renal failure. METHODS One hundred patients with postoperative oliguric or anuric renal failure despite adequate postoperative cardiac output and hemodynamic function were randomized. Forty patients (group A) were given intermittent doses of diuretics (furosemide, bumetadine, and ethracrynic acid) and fluids. Sixty patients (group B) were given continuous infusion of the solution of mannitol, furosemide, and dopamine; the infusion was started within 6 hours (mean 3.5 hours) in subgroup B1 (n = 30), and later than 6 hours (mean 7.5 hours) in subgroup B2 (n = 30) after the onset of renal failure. RESULTS Diuresis occurred in 93.3% of group B (n = 56) versus 10% in group A (n = 4; patients with preop normal renal function). Ninety percent of group A (n = 36) required dialysis versus only 6.7% of group B (n = 4; patients with preexisting renal disease of subgroup B2). Renal function returned to preoperative normal (serum creatinine 0.9 +/- 0.05, p < 0.0001) or baseline value (serum creatinine 2.5 +/- 0.01, p < 0.0001) after first postoperative week in subgroup B1 and third postoperative week in subgroup B2. CONCLUSIONS Infusion of solution of mannitol, furosemide, and dopamine promoted diuresis in patients with acute postoperative renal failure with adequate postoperative cardiac output and had decreased the need for dialysis in the majority of patients. Early administration of this solution in acute renal failure caused early restoration of renal function to normal or baseline status. It remains to be determined whether routine administration of this solution in the early postoperative period for oliguric renal failure influences the long-term mortality and morbidity in those patients who do require dialysis.

Management of catheter-induced pulmonary artery perforation: a rare complication in cardiovascular operations

BACKGROUND Pulmonary artery perforation is a rare but often fatal complication of the pulmonary artery catheter occurring in cardiovascular operations and at catheterization facilities. We used our experience and a review of the literature to formulate diagnostic and management strategies. METHODS During a 13-year period, 12 patients with pulmonary artery perforations were treated in a center that performed an average of 860 open-heart procedures per year. Clinical presentation varied from minor hemoptysis to major airway hemorrhage, hypoxia, exsanguination, and cardiac arrest. Airway bleeding occurred shortly after weaning from cardiopulmonary bypass in 5 patients or postoperatively after wedging the catheter in 6. One patient developed a hemothorax and had a cardiac arrest. Treatment included assurance of gas exchange, endobronchial lavage, isolation of the bleeding bronchus and control of hemorrhage by conservative therapy, pulmonary resection, pulmonary artery repair, and arterial embolization. RESULTS Five of the 12 patients died (42%). Recurrent hemorrhage occurred in 40% of patients (2 of 5) treated conservatively compared with none of the patients (0 of 7) having surgical treatment. Forty three percent of patients (3 of 7) treated surgically died; 20% of patients (1 of 5) treated conservatively died. One patient succumbed without treatment. CONCLUSIONS Pulmonary artery perforation is a rare and often fatal complication of pulmonary artery catheterization. This was apparent with patients who had airway hemorrhages as a result of weaning from cardiopulmonary bypass or after balloon inflation. Recurrent and fatal hemorrhage was frequent in patients treated by conservative therapy alone. Surgical intervention was effective in control of hemorrhage but did not reduce the number of deaths. Treatment remains highly individualized. It is advisable to be cautious in inserting Swan-Ganz catheters and to avoid their use unless absolutely necessary.

Angiotensin Converting Enzyme Inhibitor Therapy in Severe Postcardiotomy Dysfunction: A Prospective Randomized Study

Abstract Background: Occurrence of severe postcardiotomy dysfunction requiring prolonged postoperative support with intra‐aortic balloon counterpulsation (IABP) and inotropes, complicating surgery for coronary artery disease and valvular heart disease carries important hospital morbidity and mortality. This study evaluated the impact of angiotensin converting enzyme inhibitor (captopril) therapy in these patients in the early postoperative period. Methods: During a 5‐year period, 298 patients with prolonged diminished cardiac output required support (> 48 to 72 hours) with IABP plus two or three inotropes. This cohort was randomized to two groups, group A (195 patients) who were continued on IABP and inotropes alone and group B (103 patients) who were given an angiotensin converting enzyme (ACE) inhibitor, captopril 48 to 72 hours postoperatively and continued on IABP and inotropes. Results: Tissue perfusion and he‐modynamic parameters improved (p < 0.0001) in group B with early termination of IABP (duration of support mean 86 hours in group B vs 169 hours in group A) and inotropes. Peak improvement in tissue perfusion and hemodynamic parameters correlated with decreased serum angiotensin converting enzyme levels. Hospital mortality occurred in 31% of patients in group A and 14.5% in group B. Morbidity complications developed in 37% of patients in group A and 20% in group B. The average length of hospital stay in group A was 27 days and 17 days in group B. Cardiac, pulmonary, infective, gastrointestinal, renal, and neurological complications were common in both groups. Conclusion: Administration of ACE inhibitors in the early postoperative period to patients with severe postcardiotomy dysfunction caused improvement in tissue perfusion with decreases in mortality, morbidity, and length of hospital stay. These drugs, by effectively limiting physiological effects induced by renin angiotensin‐aldosterone axis and other mechanisms, caused recovery of stunned myocardium. More randomized trials are needed before recommending these drugs for routine use in similar patients. (J Card Surg 1998;13;11–17)

Pulmonary venous aneurysm presenting as a mediastinal mass in ischemic cardiomyopathy

True aneurysm of the pulmonary vein is a rare lesion and may present as a mediastinal mass. Acquired aneurysm of the right superior pulmonary vein presenting as a middle mediastinal mass in a patient with ischemic cardiomyopathy associated with severe mitral regurgitation and dilated left atrium is described. Though the natural history of this lesion is uncertain, it may progressively enlarge and become symptomatic. Presence of this lesion in this patient with cardiomyopathy may require a modification of surgical technique at cardiac transplantation or surgical resection of an aneurysm without cardiopulmonary bypass.

Chondroid Syringoma: A Rare Tumor of the Chest Wall

Chondroid syringoma, an uncommon, slow-growing, benign, sweat-gland tumor located on the upper right chest wall of a 66-year-old woman is presented. This skin adenexal tumor is typically located on the head and neck region. The unusual location of chondroid syringoma made an accurate preoperative diagnosis difficult, and diagnosis was achieved only by excisional biopsy and histopathologic examination. Total surgical excision remains the best therapeutic option to avoid tumor recurrence and close follow-up is recommended because of a rare possibility of malignant transformation and visceral metastases.

Mediastinal thymic cysts: A report of three cases

Thymic cysts are rare benign lesions of the mediastihum, comprising only 5% of all mediastinal cysts. ~ Although most of these cysts are asymptomatic and of no clinical significance, a rare few are of importance because they cause symptoms and signs, masquerading as malignant mediastinal tumors. There is little agreement, however, on the best diagnostic and therapeutic approaches to thymic cysts and the other mediastinal cysts. The three cases of thymic cysts described here posed diagnostic challenges, but all were resolved without event on surgical exploration and excision. Patients were two adult women (aged 54 and 34 years) and an adult man (aged 31 years) in whom respiratory symptoms predominated, with increasing cough, dyspnea, and weight loss of 15 to 20 pounds during a period of a few months. Chest roentegenography demonstrated a mass in the anterosuperior mediastinum in all three patients; in addition, there was a marked right tracheal shift and left upper lobe atelectasis in the 31-year-old male patient (Fig. 1). Results of computed tomographic (CT) scans of the chest differed among the three cases. A homogeneous and probably cystk: mediastinal mass with a definite, thick, fibrous capsule was found in the 54-year-old woman. Results of percutaneous fine-needle aspiration and biopsy under CT guidance were not diagnostic and did not relieve the symptoms, obtaining scanty aspirant with a few squamous elements. Total excision of this well-contained, globular cystic mass (6 × 5 cm) was performed through a median sternotomy. A tissue diagnosis of thymic cyst was made because the cyst wall containing thymic and lymphoid tissue was readily demonstrated.