A case report of concomitant surgery of mitral regurgitation and lung cancer

We report a case of 70-year-old woman who was simultaneously operated on mitral valve replacement for severe mitral regurgitation and the right middle lobectomy for adenocarcinoma through a median sternotomy. Concomitant cardiac and pulmonary operation can be safely performed through a median sternotomy excluding left lower lobectomy.     

Amrinone after cardiopulmonary bypass surgery. A case report

A 22-year-old woman underwent emergency aortic valve replacement. Administration of intravenous amrinone (Inocor; Sterling-Winthrop) enabled successful discontinuation of cardiopulmonary bypass after conventional measures had failed. The possible role of amrinone in this clinical situation is discussed.     

A surgical case for concomitant coronary artery disease and ASO with advanced colon cancer

We report a successful surgical case of concomitant severe coronary artery disease and ASO with advanced sigmoid colon cancer. This patient underwent two-stage operation. Resection of the sigmoid colon was carried out first, then CABG and aortofemoral bypass was carried out simultaneously. The surgical strategy of a patient with coronary artery disease and malignant neoplasm is still controvertial, however, it should be decided considering the severity and the symptoms of both disease. In this case, ascending aorta was used as a donor artery for aortofemoral bypass. This technique will bring those benefits, i.e., consecutive operation procedures in same operating field, obtaining abundant blood flow to lower limb and safe IABP catheter insertion from subcutaneously tunneled bypass graft.     

还原型谷胱甘肽对心肺转流心内直视手术患儿肺损伤的保护作用

目的 研究还原型谷胱甘肽(GSH)对心肺转流(CPB)心内直视手术患儿肺损伤的保护作用.方法 择期行心脏室间隔缺损修补术患儿30例,年龄2～6岁,体重12～20 kg,随机均分为GSH组(G组)和对照组(C组).G组于预充液中加入GSH 50 mg/kg,并于切皮后即刻静注GSH 50 mg/kg,C组给予等容量5%葡萄糖溶液.分别于切皮前即刻(T1)、主动脉开放后30 min(T2)、停CPB后2 h(T3)、6 h(T4)、12 h(T5)采集桡动脉血,测定血浆肿瘤坏死因子α(TNF-α)、白细胞介素8(IL-8)、丙二醛(MDA)浓度和超氧化物岐化酶(SOD)活性,并进行血气分析,计算呼吸指数(RI)和氧合指数(OI).结果 T2～T5时G组血浆MDA的浓度和RI明显低于、血浆SOD活性和OI明显高于C组(P＜0.05).T2～T5时C组TNF-α、IL-8的浓度高于T1时及G组(P＜0.05).结论 GSH可减轻CPB下心内直视手术患儿的肺损伤,其机制可能与抑制CPB的炎性反应及减轻脂质过氧化程度有关.     

盐酸氨溴索对体外循环心内直视手术患儿肺损伤的影响

目的 评价盐酸氨溴索对体外循环(CPB)心内直视手术患儿肺损伤的影响.方法 36例拟行室间隔缺损修补术患儿,年龄3～8岁,随机分为3组(n=12),A1组和A2组切皮后即刻分别静脉注射盐酸氨溴索2.25、4.50 ms/ks,C组给予等容量生理盐水.分别于切皮前即刻、CPB 20 min、开放升主动脉20 min停机2 h、停机6 h和术后12 h采集桡动脉血样,测定血浆丙二醛(MDA)浓度和超氧化物歧化酶(SOD)活性,并进行血气分析,计算呼吸指数(RI)和肺顺应性(CL).结果 与C组及A1组比较,A2组血浆MDA浓度和RI降低,血浆SOD活性升高(P＜0.05或0.01);A2组CL高于C组(P＜0.05).结论 盐酸氨溴索4.50 mg/kg可减轻CPB心内直视手术患儿肺损伤,其机制与减轻脂质过氧化反应有关.     

Staged carotid artery stent and cardiac surgery under cardiopulmonary bypass

The presence of carotid disease in patients undergoing cardiac surgery has been known to increase the risk of peri-operative strokes. However, there are some controversies surrounding carotid artery stenting (CAS) in patients undergoing cardiac surgery with carotid disease. We experienced 5 cases of staged carotid artery stent and cardiac surgery under cardiopulmonary bypass. These cases represent 1.7% of the cardiac surgery between August 2006 and June 2009 at our hospital. There were 4 male and 1 female patient whose ages range from 58 to 81 years old (mean 73.0). Two cases were symptomatic and revealed carotid artery stenosis of 50% or more. The remaining 3 asymptomatic cases had 75% or more stenosis. Wallstent RP stents were used in 3 of the cases, and PRECISE stents in the remaining 2. The mean time of carotid angioplasty and stenting was 101 ± 22 minutes. Among the 5 cases, we experienced 2 periprocedural events. One developed bradycardia and cardiac arrest due to severe aortic valve stenosis, which was promptly improved by temporary cardiac pacing. The other experienced transient hemiparesis. The mean period of time between CAS and cardiac surgery was 53 days, with a range of 23 to 78 days. There were no post-operative deaths or strokes. All 5 cardiac operations were performed successfully. Further cooperation among cardiologists, cardiac surgeons and neurosurgeons is suggested for more careful circulatory assessment during CAS in patients with severe cardiac disease.     

Aorto-coronary vein bypass and valvular surgery.

During the period 1972--1975, 26 patients underwent valvular surgery combined with aorto-coronary saphenous vein bypass at Ullev?l Hospital, Oslo. Aortic valve replacement was performed in 13 patients, mitral valve replacement in 8 and double valve replacement in 3 patients. The Bj?rk-Shiley tilting disc valve was used in all cases. A Carpentier ring was inserted in one case and an open mitral commissurotomy was performed in another. Twenty-nine saphenous vein grafts were inserted. Three early deaths (all patients in functional class IV (NYHA)) were due to myocardial failure. There were 2 late deaths (both patients in functional class III before operation) of which one was due to myocardial infarction and the other to ventricular fibrillation. The overall mortality was 19%. At follow-up with a mean observation time of 11 months, 19 of the 21 survivors were improved at least one functional class. Only 2 patients had mild angina pectoris. No valvular dysfunction was found. Twenty-one of 22 re-examined grafts were patent (95% graft patency). Valvular surgery combined with aorto-coronary vein bypass in this material shows low mortality and good clinical and haemodynamic results in patients in functional class II and III. Patients should be operated upon before they reach functional class IV, as the mortality in that group is very high.     

Does sodium nitroprusside reduce lung injury under cardiopulmonary bypass?

Objective: We hypothesized that direct pulmonary arterial infusion of sodium nitroprusside (SNP) would ameliorate lung injury under cardiopulmonary bypass. Methods: Experiments were performed on 12 adult mongrel dogs of both sexes weighing 20–28 kg. The animals were randomly divided into two groups of six animals each. All animals were subjected to total cardiopulmonary bypass (CPB) and moderate hypothermia (28°C core temperature). During total CPB, the aorta was clamped together with the pulmonary artery to prevent any antegrade flow to the lungs. After cardioplegic arrest for 120 min, the animals were rewarmed, weaned from CPB, and their condition stabilized for another 90 min. After the release of the aortic cross-clamp, the dogs received either a 5% glucose solution as a placebo (group I) or SNP (0.5 μg/kg per min) (group II), both infused into the pulmonary arterial line. The infusion was stopped after 60 min. To measure lung tissue malondialdehyde (MDA), water content and polymorphonuclear leukocytes count, lung tissue samples were taken before CPB and after weaning from CPB. In addition, alveolar-arterial oxygen difference (AaDO₂) for tissue oxygenation was calculated by obtaining arterial blood gas samples. Results: Values of MDA before CPB of 42.0±5.3 nmol/g of tissue rose to 67.6±5.7 nmol/g of tissue after weaning from CPB in group I (P=0.028). In group II MDA values also increased from 43.1±4.3 to 52.4±5.7 nmol MDA/g of tissue after weaning from CPB (P=0.046). The MDA increase in group II after CPB was found to be significantly lower than that for group I (P=0.004). The wet-to-dry lung weight ratio in the sodium nitroprusside group was 5.1±0.2, significantly lower than in the control group (6.8±0.4), (P=0.01). AaDO₂ increased significantly in group I (P=0.028). There was no statistically significant difference (P=0.065) between groups I and II. During histopathological examination it was observed that neutrophil counts in the lung parenchyma rose significantly after CPB in both groups. The increase in group I was significantly larger than that in group II (P<0.001). Conclusions: The results represented in our study indicate that pulmonary arterial infusion of sodium nitroprusside during reperfusion can reduce lung injury under cardiopulmonary bypass.     

Partial atrial resection in advanced lung carcinoma with and without cardiopulmonary bypass.

Combined pneumonectomy and partial resection of the left atrium was performed in 12 patients with advanced lung carcinoma (T3 and T4 in the new UICC classification). In the eight patients with a T3 lung carcinoma intrapericardial atrial resection with vascular clamping was carried out; four of the patients died within a year. The remaining four patients had a T4 tumour and underwent removal of the right lung and part of the left atrium under total cardiopulmonary bypass. One patient died shortly after the operation from cerebral and cerebellar infarction, and one died 11 months later from brain metastases. Two are alive and well. Complete resection appears to offer a chance for longer survival in patients with advanced lung carcinoma that extends directly into the intrapericardial pulmonary vessels or atrium.     

Myocardial protection by nicorandil during open-heart surgery under cardiopulmonary bypass

BACKGROUND: To evaluate the myocardial protective effect of nicorandil when used as an adjuvant to cold hyperkalaemic cardioplegia in open-heart surgery. METHODS: Patients who underwent surgery under cardiopulmonary bypass (CPB) for mitral valve replacement (MVR, 23 patients) or coronary artery bypass grafting (CABG, 24 patients) were entered in a double-blind study. The patients were randomized to a nicorandil Group (N) or placebo Group (P). Nicorandil 0.1 mg kg-1 (Group N), or normal saline (Group P), were administered at three time points: (1) after aortic cannulation, but prior to going on CPB, (2) 5 min before aortic cross-clamping and (3) 5 min before reperfusion. The following variables were studied: (a) time until electromechanical arrest after cardioplegia administration (Tarrest), (b) time until return of electromechanical activity after aortic cross-clamp removal (Trecovery), (c) incidence of postoperative myocardial infarction or low output syndromes (d) dysrhythmias requiring intervention after aortic cross-clamp removal and (e) haemodynamic changes after nicorandil administration. RESULTS: The Tarrest after cardioplegia administration was significantly faster in nicorandil group in both MVR and CABG patients (P 75 IU L-1 in MVR patients was significantly lower in the Group N than in placebo patients (P < 0.05). However, in CABG patients there was no such significant difference. The incidence of dysrhythmias requiring intervention after aortic cross-clamp removal was also less in Group N. Administration of 0.1 mg kg-1 boluses of nicorandil did not cause significant haemodynamic changes or precipitate dysrhythmias in any patient. CONCLUSION: Nicorandil enhances the myocardial protective effect of cold hyperkalaemic cardioplegia in cardiac surgery patients.     

Differences in hemodynamic effects of amrinone, milrinone and olprinon after cardiopulmonary bypass in valvular cardiac surgery

The differences in hemodynamic effects of amrinone, milrinone and olprinone were evaluated in 46 patients for valvular cardiac surgery after cardiopulmonary bypass (CPB). Patients were randomly allocated to three groups; group A with amrinone infusion (17 patients); group M with milrinone infusion (15 patients); and group O with olprinone infusion (14 patients). Each drug was administrated as a single dose into the venous reservoir of the CPB circuit 15 min prior to the end of emergence from CPB, followed by continuous infusion. Hemodynamic parameters were measured at the time of preCPB (C0), just after the end of CPB (C1), one hour after the termination of CPB (C2) and after the chest closure (C3). Catecholamines were used in order of dopamine, norepinephrine and dobutamine. These doses were modulated to maintain the cardiac index > 3.0 l.min-1.m-2 by each anesthesiologist. Hemodynamic parameters (at C0, C1, C2 and C3) and the doses of cathecholamine (at C1, C2 and C3) were compared among the 3 drugs. The systolic blood pressure in group M was significantly higher than that of group A and group O after chest closure. In group M and A, the systolic blood pressure showed a significant increase after CPB. On the other hand, the systolic blood pressure showed no significant change in group O after CPB. Three drugs showed no significant difference in the dosages of catecholamines used.     

Comparison of coronary bypass surgery with and without cardiopulmonary bypass in patients with multivessel disease

BACKGROUND: Coronary artery bypass grafting can now be performed with or without cardiopulmonary bypass. Our objective was to determine whether off-pump coronary artery bypass grafting is associated with better early outcomes compared with conventional coronary artery bypass grafting. METHODS: In 4 centers with off-pump coronary surgery experience, a retrospective analysis of all coronary artery bypass grafting in a 3-year period was performed. Groups were compared to determine selection criteria, mortality, and morbidity, then computer-matched by propensity score to control for selection bias. Multivariate logistic regression identified risk factors predictive of mortality. Specific subgroups most likely to benefit were identified. RESULTS: In all, 17,401 isolated coronary artery bypass grafts were performed, 7283 (41.9%) off-pump coronary artery bypass grafts and 10,118 (58.1%) conventional coronary artery bypass with cardiopulmonary bypass. Factors determining selection of patients for off-pump coronary artery bypass grafting included female gender (55.5% vs 44.5%), preexisting renal failure (57.0% vs 43.0%), and reoperations (52.6% vs 47.4%). Operative mortality was 2.8%; off-pump coronary artery bypass grafting versus conventional coronary artery bypass with cardiopulmonary bypass (1.9% vs 3.5%, P <.001) had the same predicted risk. Of the patients with multivessel disease, 11,548 were matched by propensity scoring. Mortality was significantly less in the off-pump coronary artery bypass grafting group (2.8% vs 3.7%, P <.001). By multivariate logistic regression analysis of the matched sample, predictors for mortality were female gender (odds ratio 1.83, confidence interval 1.37-2.44), preexisting renal failure (odds ratio 2.85, confidence interval 2.64-4.95), history of stroke (odds ratio 1.74, confidence interval 1.08-2.80), previous coronary artery bypass grafting surgery (odds ratio 4.22, confidence interval 2.92-6.09), use of cardiopulmonary bypass (odds ratio 2.08, confidence interval 1.52-2.83), and recent myocardial infarction (odds ratio 2.31, confidence interval 1.68-3.22). Cardiopulmonary bypass was predictive of mortality in reoperations, female patients, and patients aged >or= 75 years. Off-pump coronary artery bypass grafting was associated with less morbidity, including reductions in blood transfusion (32.6% vs 40.6%, P <.001), stroke (1.4% vs 2.1%, P =.002), renal failure (2.6% vs 5.2%, P <.001), pulmonary complications (4.1% vs 9.5%, P <.001), reoperation (1.7% vs 3.2%, P <.001), atrial fibrillation (21.1% vs 24.99%, P <.001), and gastrointestinal complications (3.6% vs 4.8%, P =.02). CONCLUSION: In 4 centers with beating-heart operation experience, there is an overall early benefit in off-pump surgery, especially in patients traditionally considered at high risk for coronary artery bypass grafting.     

体外循环心脏手术对甲状腺激素代谢的影响

目的 观察体外循环心脏手术前后甲状腺激素的变化,研究春对甲状腺激素代谢的影响。方法 用放射免疫法测定３０例体外循环心脏手术患者术前、术中、术后血浆甲状腺激素激素和促状腺激素的浓度。结果 三碘甲状腺原氨酸（Ｔ３）、甲状腺 素（Ｔ４）、游离三碘甲状腺原氨酸（ＦＴ３）术中降低,术后２ｈＴ４恢复正常。Ｔ３、ＦＴ３呈下降低趋势,术后２４ｈ降至最低。ＦＴ４手术前后差异无显著性,ｒＴ３术后２４ｈ明显升高。ＴＳＨ     

乌司他丁在婴幼儿心肺转流心脏直视手术中的应用

目的 比较乌司他丁（UTI）和抑肽酶在婴幼儿心肺转流（CPB）心内直视手术期间对炎性介质和细胞因子的抑制作用以及对呼吸系统总顺应性的影响。方法 48例室间隔缺损（VSD）患儿随机分为四组：U组,UTI 10 kIU／kg;Ap组,抑肽酶100 klU／kg;UA组,UTI 5 kIU／kg加抑肽酶100 kIU／kg和C组（对照组）,每组12例。于麻醉诱导后（T4）、CPB结束（T2）和术后2h（T3）采血检测白细胞介素-6（IL-6）、IL-8、IL-10和肿瘤坏死因子α（TNF-α）。并同时监测血液动力学和呼吸系统总顺应性（Crs）等。结果 CPB期间C组和Ap组的IL-6、IL-8血浆水平增高幅度较为显著（P〈0．01）。且术后恢复较慢;IL-10在T2时除Ap组仅有轻微改变外,其余三组均升高（P〈0．01）,至T3时仍呈升高趋势;各组TNF-α的血浆水平升高均较为显著（P〈0．01）,尤以C组为甚。血浆细胞因子和炎性介质的改变与呼吸功能呈负相关,U组Crs变化轻微,其他各组Crs均显著降低。结论 UTI能安全有效地应用于婴幼儿,通过抑制CPB心脏直视手术患儿围术期促炎细胞因子的释放,减轻CPB引起的急性炎症反应,改善呼吸系统顺应性而具肺保护功能。其作用较抑肽酶显著。     

Tracheal reconstruction with mitral valve replacement under cardiopulmonary bypass: A case report

A-54-year-female patient suffering from rheumatic heart disease mitral stenosis, NYHA class IV with pulmonary edema ventilated for one week. She developed postintubation tracheal stenosis. Mitral valve replacement with tracheal resection and reconstruction under Cardio Pulmonary Bypass (CPB) was planned. Mitral valve replacement was done under CPB which was continued to resect and reconstruct trachea. Endotracheal tube was reinserted beyond anastomosis and ventilation started. Postoperatively neck flexon stitch kept for one week and repeat fibreoptic bronchoscopy was done to clear endotracheal secretions. postoperative period was uneventful except left vocal cord palsy.     

Management of concomitant occlusive disease of coronary and carotid arteries using cardiopulmonary bypass for both procedures

The incidence of neurological complications following operative treatment of concomitant occlusive disease of coronary and carotid arteries has been reported to be between 0.7 and 18 per cent by different preoperative screening methods and surgical strategy. From the opening of our institution in November 1984 until March 1988 5443 open-heart procedures were performed. In 116 patients of 3540 consecutive coronary artery bypass grafting (CABG) candidates simultaneous carotid endarterectomy (TEA) was carried out because of hemodynamically relevant stenosis of one or both carotid arteries; 50 patients were neurologically symptomatic with TIA's and amaurosis fugax preoperatively. Sixty of 66 patients with asymptomatic carotid artery stenosis had either a morphologically severe stenosis of the carotid artery or multifocal occlusive disease of the extracranial supraaortic arteries. Prior to carotid-TEA cardiopulmonary bypass was inserted with mild hypothermia maintaining a beating heart for pulsatile body perfusion. An intraluminal shunt was only used in patients with bilateral carotid stenosis. Intraoperative EEG-monitoring was carried out to detect cerebrovascular insufficiency. In 108/116 patients no neurological complications were observed, but 6/116 patients had transient minor neurological symptoms. Two of 116 patients sustained a severe neurological deficit with hemiplegia and one of them died on the 21st postoperative day. Based on these data we conclude that patients requiring carotid TEA and CABG should be operated upon simultaneously using cardiopulmonary bypass for both procedures.