Biomedical subjects
Publications and source records attributed to M Goenen.
We present the case of a 57-year-old woman with a huge tracheal laceration after intubation. With simple supportive therapy, the laceration healed in ten days, and the patient made an uneventful recovery. At the three-month follow-up, no sequelae were observed.
Twenty-three of 514 (4.6%) patients who underwent cardiac surgery in 1988 with cardiopulmonary bypass were later reoperated for sternal complications. Several risk factors, including pre-, intra and postoperative variables, have been investigated. A significant correlation was found with the presence of diabetes mellitus, the type of operation (bilateral internal mammary artery grafting), early reoperations, haemodynamic alterations, pulmonary infections and incidence of serious non infectious complications. The different sternal complications are analyzed from a clinical and therapeutic point of view.
The conventional surgical treatment of isolated critical stenosis of the left main coronary artery restores a less physiologic perfusion of the myocardium, leads to occlusion of the left coronary ostium, and consumes an appreciable length of bypass material. Starting in June 1985, 23 surgical angioplasties have been performed in 22 patients. The left main stem was approached posteriorly in the first 11 patients, and an anterior approach was preferred in the last 12 because of better exposure. The onlay patch consisted of saphenous vein in the first 14 patients; pericardium was preferred in the last nine. The five failures occurred early. Four of these occurred in patients older than 60 years in whom calcifications of the left main stem had been seen on the preoperative angiogram. Eighteen procedures (78.3%) succeeded, but one patient (5.5%) died later of a massive air embolism. The 17 survivors are free of symptoms (maximal stress test combined with thallium scintigraphy) after a mean follow-up of 24.3 months. Angiographic restudy at an average of 8 months was obtained in 14 patients (82.3%) and revealed an excellent result in 13. In five patients, a late angiographic restudy (22 to 37 months) still revealed perfect patency of the left main stem. Provided that well-defined contraindications (calcifications, involvement of the distal bifurcation, older age) are respected, surgical angioplasty deserves a place in the array of surgical strategies.
The pathophysiological understanding and management of acute and chronic heart failure have changed dramatically in the past decade. Since the early 1980s, a major effort has been made to develop nonglycosidic, noncatecholamine agents that combine inotropic and vasodilating properties, in order to treat myocardial dysfunction unresponsive to current therapy. Within this context, increasing attention has been paid to the role of intracellular cyclic adenosine monophosphate (cAMP) in myocardial contractility. The pharmacologic use of catecholamines to stimulate beta-receptors activates adenylate cyclase, which in turn leads to an increase in intracellular levels of cAMP. In addition, phosphodiesterase 3 (PDE 3) inhibition may prevent the degradation of cAMP, thus maintaining high intracellular levels of the substance. Intravenous amrinone has been shown clinically to improve hemodynamic status remarkably in the patient experiencing a low cardiac output syndrome, by increasing CO while decreasing filling pressures and pulmonary arterial pressures, without increasing myocardial O2 demand. This report will review several studies of different types of patients and explain the effects of amrinone alone and in combination with the more traditionally used catecholamines. It must be stressed that amrinone, in spite of its dual action of inotropy and vasodilation, should not be considered a rival to catecholamines but rather an enhancer of them, which clinicians should consider using in the early stages of therapy in many different settings.
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Between September 1985 and November 1987, 246 sequential mammary grafts were performed in 231 consecutive patients. Seventy-eight percent had triple vessel disease, and 33% required an urgent procedure. The length of the internal mammary artery pedicle was the only limitation to its use. No account was taken of the free cut-end flow of the internal mammary artery. There were 14 bilateral sequential mammary grafts and 15 free sequential mammary grafts. Of the 531 sequential mammary anastomoses, 482 were built with the left internal mammary artery; 113 (21%) were diamond-shaped anastomoses. The right internal mammary artery was brought through the transverse sinus in 44 cases, 10 times for sequential grafting of circumflex branches. Taking into account the adjunctive venous anastomoses and the single internal mammary artery anastomoses, there were 4.5 distal anastomoses per patient, 2.8 being mammary anastomoses and 2.3 being sequential mammary anastomoses. The hospital mortality rate was 2.6%. The prevalence of perioperative myocardial infarction was 5.2%. Follow-up was complete and averaged 15.4 months. Six patients (2.7%) still had angina pectoris. One hundred fifty-seven (71%) patients were recatheterized 6 months after the operation, and 95% of the sequential mammary anastomoses were still patent. The patency rate of the diamond-shaped mammary anastomoses was 94.5% and that of the anastomoses corresponding to the right internal mammary arteries brought through the transverse sinus was 94.3%. The gratifying functional results (maximal stress test combined with exercise thallium scintigraphy) obtained at an average of 6 months postoperatively illustrated the surprising physiologic adaptability of the internal mammary artery. As the attrition rate of the mammary artery grafts beyond 6 months postoperatively is thought to be minimal, gratifying long-term results with widespread use of sequential mammary grafts can be anticipated.
A case of anesthesia for a heart-transplant operation on a patient on mono-amine oxidase inhibitors (M.A.O.I.) is reported. This 63-year-old farmer was in end-stage cardiac failure due to familial cardiomyopathy. For 24 hours before surgery, he was on a dobutamine infusion (3 mcg/kg/min). He had been taking nialamide (100 mg/day) for 8 years for reactional depression and had not stopped it, despite advice. Anesthesia was induced with etomidate and succinylcholine, and maintained with fentanyl (25 mcg/kg/min) and pancuronium. Cardio-vascular stability was maintained during induction and first stage of surgery, up to cardectomy. Graft ischemia was 188 minutes. Successful defibrillation occurred after verapamil 3 mg. Weaning from C.P.B. was easy with dopamine (5 mcg/kg/min) and isoprenaline (0.01 mcg/kg/min). Post-operatively, on day 1, hypertension appeared and needed a nitroprusside infusion. On day 3, the patient needed another anesthetic for removal of pericardial clots, without problems. He remained very confused and disorientated during all his stay in hospital, but improved greatly with a neuroleptic. He left the hospital on day 28 in a good shape, with an anxiolytic, captopril and immunosuppressors. One month later, he was back on nialamide. The pharmacology of the M.A.O.I. is reviewed and their interactions with anesthesia are discussed as well as the use of inotropes. In this case, the denervated heart-graft, free from M.A.O. inhibition, behaved normally when transplanted in a chronically M.A.O.I. treated recipient.
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Preoperative left ventricular function variables were evaluated as potential risk factors for peroperative and postoperative complications in 183 consecutive patients undergoing coronary bypass surgery. Fifty-six patients had no abnormal criteria and 127 had at least one criterion (AN). The incidence of history of infarction was significantly greater in the AN (71.6 percent) than in the N (39.6 percent) group (p less than 0.04). During the early postoperative course, N and AN differentiated significantly in (1) the need for inotropic therapy (II vs 30 percent, p less than 0.05); (2) intra-aortic balloon pump (0 vs 13 percent); (3) arrhythmias (20 and 40 percent, p less than 0.002); and (4) stay in the Intensive Care Unit (2.3 +/- 0.8 and 3.9 +/- 2 days, p less than 0.01). Perioperative necrosis and mortality were not different. During a follow-up period of two years, N and AN did not show any difference in mortality and recurrence of angina.
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Hemodynamic effects of amrinone were studied in 2 groups of patients after open heart surgery. Group I consisted of 10 patients with moderate heart failure. In the absence of inotropic agents, their mean cardiac index (CI) was 2.02 +/- 0.41 liters/min/m2 and mean pulmonary capillary wedge pressure (PCWP) 19 +/- 3 mm Hg. Amrinone was administered 24 hours postoperatively by bolus injection (2 mg/kg) and by 12-hour infusions (20 micrograms/kg/min). Hemodynamic data and plasma concentrations were obtained 10 and 20 minutes after the bolus injection and at 1, 4, 8 and 12 hours during infusion. Significant beneficial changes were noted in CI, PCWP, right atrial pressure, systemic vascular resistance and pulmonary vascular resistance. Group II consisted of 5 patients in severe cardiogenic shock (mean CI 1.97 +/- 0.3 liters/min/m2, mean PCWP 28 +/- 8 mm Hg) despite adrenergic agonists in all patients and intraaortic counterpulsation in 2. After these measures, amrinone was given intravenously for 36 to 72 hours as additional inotropic support. Significant improvement was observed in CI, PCWP, right atrial pressure, systemic vascular resistance and pulmonary vascular resistance. Four patients in this group were discharged; 1 patient died after 5 days in acute renal failure and coma grade IV. No serious adverse effects of amrinone were observed in any group II patient.(ABSTRACT TRUNCATED AT 250 WORDS)
A patient presented the rare complication of a dissecting aneurysm of the ascending aorta ruptured into the superior vena cava producing a left-right fistula. Continuous oximetric measurements by a fiberoptic pulmonary artery floated catheter was used to localize the site of the shunt. Emergency surgical repair was successfully performed.
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This paper presents the authors' initial experience with a new technique for continuous monitoring of the mixed venous oxygen saturation (SvO2) during and after open heart Surgery. The method uses reflectometric measurements of SvO2 via a fiberoptic pulmonary artery catheter with the capability for thermodilution cardiac output estimates. Changes in SvO2 reflect changes in one or more of the three interacting factors of the Fick equation: arterial oxygen content, cardiac output, and total body oxygen utilization. Intra-and postoperative examples illustrate these various situations. The very short response time of the System allows for early diagnostic and therapeutic decisions.
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One hundred and twenty two cases of severe hyaline membrane disease are reported. 68 of them survived (57%). Adverse clinical, radiological and laboratory factors, and their effects on the early mortality rate, are analysed with particular reference to the referring centers, delay in admission, transport and the critical state of most infants on admission. The follow-up of 29 survivors treated before 1974 has been examined with reference to birthweight and assisted respiration. Four (30%) of the twelve infants with birthweights below 2000 g had major neurological sequelae. Only two out of the 17 babies with a birthweight over 2000 g had minor mental disturbances.