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Patients with hemophilia A (Hem A) requiring cardiopulmonary bypass–supported cardiac surgery pose unique challenges for perioperative hemostatic management. This report describes a staged perioperative approach to clinical hematologic management as applied to an 80-year-old male of O-positive blood type with mild Hem A, who underwent successful, uncomplicated coronary artery bypass graft surgery. Hematologic management primarily consisted of normalization of plasma factor VIII levels followed by standard care. Conventional laboratory methods and point-of-care-testing methods such as thromboelastography and heparin management assays were combined to guide patient care. Minimal blood loss and minimal hemodilution techniques were also used to achieve favorable outcomes. The thorough preparation and execution of care by our multidisciplinary team from perfusion, pathology and laboratory medicine, cardiovascular surgery, transfusion services, nursing, and anesthesia, facilitated a safe, smooth, clinical course and an optimal outcome.

The regulation of apoptosis in atherosclerosis is not completely defined. The aim of this study was to determine the expression of Bcl-2, Bcl-x, Bax, and Bak in relation to apoptosis in advanced atherosclerotic lesions. In atherectomy (15), endarterectomy (10), and control non-atherosclerotic segments of renal (2) and of coronary and carotid (5) arteries, the extent of apoptosis was determined using TdT dUTP nick end labelling (TUNEL) and nuclear morphology (karyorrhexis/pyknosis) and expression of apoptosis regulators by immunohistochemistry and western blot analysis on paraffin-embedded material. In all specimens, the atherosclerotic involvement was advanced: grade V (n=18) and grade VI (n=7). The apoptotic index was high (mean 30%) in advanced lesions compared with controls (

We present a case of a 30-year-old woman with a history of HIV and hepatitis C who sought medical attention because of severe oedema of the lower limbs and abdomen. CT of the chest showed a thickened pericardium, and cardiac catheterisation demonstrated constrictive physiology. She underwent pericardiectomy, but the procedure was unsuccessful because the pericardium was densely adherent to the myocardium. After consultation with several pathologists, she was diagnosed with primary pericardial mesothelioma (PPM), an exceedingly rare cardiac tumour with a fatal prognosis. She died within 3 months of presentation. The details of the case as well as pertinent literature are reviewed.

Background . The midterm clinical and hemodynamic performance of the Medtronic Mosaic porcine bioprosthesis was evaluated in a regulatory trial. Methods . In nine Canadian centers, 802 bioprostheses (560 aortic and 242 mitral) were implanted between September 1994 and April 1999 in patients with a mean age of 70 years. Results . Survival for aortic valve replacement at 4 years was 84.4% ± 3.1%. Freedom from valve-related or unexplained death was 95.6% ± 1.9%; structural valve deterioration, 100.0%; reoperation, 96.2% ± 1.7%; major thromboembolism, 96.1% ± 1.8%; and major antithrombotic-related hemorrhage, 96.4% ±1.7%. Echocardiographic derived mean systolic gradient was 13.4 mm Hg at 4 years with an indexed effective orifice area of 0.7 to 0.8 cm 2 /m 2 . A significant decrease in left ventricular mass was shown over time in all valve sizes. Survival for mitral valve replacement at 4 years was 79.2% ± 6.8%. Freedom from valve-related or unexplained death was 96.5% ± 3.4%; structural valve deterioration, 100%; reoperation, 97.0% ± 3.2%; major thromboembolism, 95.7% ± 3.8%; and major antithrombotic-related hemorrhage, 95.0% ± 4.2%. Echocardiographically measured averaged mean diastolic gradient was 4.5 mm Hg. Conclusions . The Medtronic Mosaic bioprosthesis is safe and effective in both the aortic and mitral positions. The valve has low gradients in both positions and excellent left ventricular mass regression in the patients with aortic valve replacement.

Background . The Medtronic (Minneapolis, MN) Mosaic porcine bioprosthesis is an investigational prosthesis which incorporates zero-pressure fixation, aortic root predilation, low profile stent, and alpha oleic acid antimineralization treatment. Methods . From September 1994 to August 1996, 289 patients (mean age 70 years, range, 28 to 88 years) had 227 (78.5%) aortic valve replacements and 62 (21.5%) mitral valve replacements. Concomitant procedures were performed in 61.2% (139) of aortic valve replacements and 54.8% (34) of mitral valve replacements. Of the aortic valve replacement group 70 (30.8%) were in the 61 to 70 age group and 134 (59.0%) were 71 years or older. Of the mitral valve replacements, 23 (37.1%) were 61 to 70 years and 30 (48.4%) 71 years or older. Results . The early mortality, overall, was 4.2% (12 of 289); for aortic valve replacement it was 4.0% (9) and for mitral valve replacement it was 4.8% (3). The late mortality for aortic valve replacement was 2.6% per patient-year (3 events, 1.3% of total) and for mitral valve replacement it was 3.3% per patient-year (one event, 1.6% of total). The reoperative rate for aortic valve replacement was 3.0% per patient-year (4), while there were no mitral valve replacement reoperations. The freedom from major thromboembolism was 97.3% ± 1.6% for aortic valve replacement and 94.7% ± 3.0% for mitral valve replacement at 1 to 1.5 years. The freedom from reoperation was 96.7% ± 1.7% for aortic valve replacement; there was no reoperation for mitral valve replacement. There were no cases of structural valve deterioration. In the aortic position the mean systolic gradient was low, approximately 11 mm Hg, across all sizes (range 8 to 12 mm Hg at 3 months and 10 to 13 mm Hg at 12 months). In the mitral position the mean diastolic gradient was approximately 5 mm Hg (range, 2 to 6 mm Hg) for all sizes 25 to 31 mm at the early and 1 year follow-up echocardiographic assessment. Conclusions . The early clinical performance and in vivo hemodynamics are encouraging.

To determine whether inclusion of a neutrophil-specific filter into the extracorporeal circuit during open heart valve surgery alters postoperative outcomes.Convenience sampling of 24 patients undergoing elective open heart valve surgery between July 1993 and June 1994. Patients were randomized to a neutrophil-specific filter (n = 11) or to a standard blood filter (n = 13) during cardiopulmonary bypass.Neutrophil-specific filter diminished (P0.02) the expression of CD18, a neutrophil surface adhesion molecule, at I (84.5 +/- 4.2 vs 94.8 +/- 3.8%), 4 (80.0 +/- 4.2 vs 95.1 +/- 3.9%) and 24 hr (75.2 +/- 4.2 vs 98.2 +/- 3.9%) post-operatively compared with standard filter. Total white blood cell count, neutrophil count, and pro-inflammatory cytokines (IL-6, IL-8) were similar between groups at all times. Measured outcomes including: PaO2 cardiac index, ejection fraction, haemodynamic variables, use of inotropes, spirometry (FEV1, FVC), and hospitalization duration were similar between groups.Inclusion of the neutrophil filter during open heart valve surgery selectively depletes activated neutrophils. There were no other detectable differences between the two groups and the use of a neutrophil-specific filter in routine clinical practice for patients undergoing open heart valve surgery is not supported.

Study objective To determine whether higher personnel intensive chest physical therapy can prevent the atelectasis that routinely follows cardiac valve surgery. Design Randomized, controlled trial. Setting Tertiary care hospital. Patients Seventy-eight patients undergoing elective cardiac valve surgery between October 1991 and April 1993 were enrolled. Interventions Patients were randomized in an unmasked fashion to receive early mobilization and sustained maximal inflations (lower-intensity treatment) or to receive early mobilization, sustained maximal inflations, and single-handed percussions (higher-intensity treatment). Measurements and results Clinical efficacy was determined by extent of atelectasis, length of ICU stay, total length of hospital stay, and personnel costs. The extent of postoperative atelectasis was similar in both groups on the fifth postoperative day. Postoperative values of FVC and FEV 1 were reduced to a similar extent in both groups. Hospital stays and ICU stays were similar regardless of treatment. Physical therapy costs were highest in the higher-intensity therapy group. Conclusions Postoperative respiratory dysfunction is common but does not usually cause significant morbidity or prolong hospital stay. The routine prescription of high-intensity physical therapy does not improve patient outcomes but does add significantly to patient costs.

A pulmonary injury of varying severity occurs routinely after cardiopulmonary bypass. We studied the pulmonary complications of partial cardiopulmonary bypass in four groups of dogs to better define the injury and to evaluate the efficacy of two interventions (addition of a leukocyte filter or cyclooxygenase inhibition) on preservation of systemic oxygenation. All animals received a standard anesthetic (pentobarbital, morphine, and vecuronium) and, after sternotomy, three groups of animals received 3 hours of partial cardiopulmonary bypass. The animals were randomized to receive partial bypass alone ( n = 6), indomethacin and bypass ( n = 5), or a leukocyte filter and bypass ( n = 5). A fourth group ( n = 5) did not receive bypass and served as a time control. We measured blood gases and also obtained histologic samples to assess the degree of lung injury. We found that bypass alone caused a significant reduction ( p

Aortocoronary bypass surgery has undergone recent changes, promoting the concept of "fast tracking," in which patients are extubated and discharged postoperatively at an accelerated pace compared with previous historic patterns. Postoperative respiratory function and complications have not been previously studied in patients selected for "fast tracking."Matched retrospective cohort study.Referral university teaching hospital.Thirty-one patients who were compared with a retrospective matched cohort of 112 patients. Matching was based on forced vital capacity, age, and gender.Respiratory physiological outcomes defined as pneumonia, postoperative pulmonary spirometry, chest x-ray atelectasis or lobar collapse, and gas exchange were compared.The increase in atelectasis score compared with preoperative (0 = no atelectasis, 4 = lobar collapse) was higher (p0.01) on the day of extubation in the late extubation group (4.1 +/- 1.4) compared with the early extubation group (2.6 +/- 1.3). These chest radiographic findings were not related to pain (0 to 10 visual analog scalei, which were equivalent between groups (4.0 +/- 2.3 v 4.2 +/- 1.6). The decreases in spirometry on postoperative day 5 (FVC 1.15 +/- 0.42 v 0.86 +/- 0.54 liters; FEV1 0.92 +/- 0.38 v 0.59 +/- 0.50 liters) were greater (p0.001) in the late extubation group. A significantly (p0.001) greater decrease in FEV1/FVC ratio in the late extubation group (3.25 +/- 0.87 v -1.6 +/- 1.11%) was indicative of greater airway obstruction. Fluid balance until extubation was greater in the late extubation group (4.0 +/- 2.1 v 1.4 +/- 1.2 liters).Differences in chest radiographs in the late extubation group at the time of extubation may be related to greater use of fluids or increased airway obstruction. The rationale of early extubation is based on cost minimization to decrease hospital duration. This article suggests that respiratory physiological outcomes are not worsened in patients who are extubated and discharged early after elective aortocoronary bypass surgery.

Purpose: Cardiopulmonary bypass is associated with activation of neutrophils, which may adhere to vascular endothelium causing lung, heart, and brain injury. We tested whether blocking neutrophil adherence would improve organ function following cardiopulmonary bypass in dogs. Ulbar|Materials and Methods: All dogs received a standard anesthetic, and then one group (n = 6) received 2 hours of cardiopulmonary bypass followed by 4 hours of observation. A second group (n = 6) received a monoclonal antibody (6 mg/kg) to CD18, a neutrophil adherence factor, immediately before cardiopulmonary bypass. A third group (n = 6) did not receive cardiopulmonary bypass or antibody. Results: Using flow cytometry we found that the antibody bound essentially all neutrophil CD18 sites. All three groups had similar gas exchange and hemodynamics. Lung and heart histology results were similar between groups. By echocardiography, five animals receiving cardiopulmonary bypass alone showed regional wall abnormalities, whereas only one receiving antibody showed wall motion abnormality (P < .05). Following cardiopulmonary bypass, intracellular myocardial pH was higher (P < .05) in the antibody-treated group compared with the group that had cardiopulmonary bypass alone (7.23 ± 0.05 v 7.07 ± 0.07 respectively). Conclusion: Monoclonal antibodies to CD18 can prevent the deterioration in cardiac function routinely observed following cardiopulmonary bypass.

Study Objective: Cardiac surgery is complicated by decreased postoperative respiratory muscle strength and spirometry with accompanying increased atelectasis. The specific respiratory symptoms attributable to these physiologic changes are unknown, and this study looked at the symptoms and underlying physiology. Design: Convenience sampling of observational cohort. Setting: Tertiary care university hospital. Patients: One hundred thirty-eight patients undergoing elective surgery were enrolled. Interventions: Changes from admission to 8-week postoperative values in atelectasis, pleural effusions, spirometry (forced vital capacity and forced expiratory volume in one second), and respiratory muscle strength (negative inspiratory pressure) were measured. These physiologic changes were compared with changes in respiratory symptoms of cough, wheeze, phlegm, and dyspnea on walking up a slight hill noted from admission to 8-week follow-up by stepward logistic regression. Measurements and Results: Spirometry and negative inspiratory pressure decreased and atelectasis increased from admission to discharge. These disturbances had only incompletely resolved at 8-week follow-up. Some patients reported fewer symptoms of cough (11%), phlegm (9%), wheeze (35%), and dyspnea (46%) at 8 weeks follow-up. Other patients reported increased symptoms of cough (15%), phlegm (10%), wheeze (6%), and dyspnea (4%) at 8 weeks follow-up. Residual atelectasis at 8 weeks was predictive of fewer symptoms of dyspnea (odds ratio [OR] 0.335, p = 0.199; 95% confidence interval [CI] 0.188, 0.597], increased symptoms of dyspnea (OR 855, p = 0.006; 95% CI 6.6, 11052), and increased symptoms of cough (OR 260, p = 0.023; 95% CI 2.13, 31829). Negative inspiratory pressure at 8 weeks was predictive of fewer symptoms of dyspnea (OR 1.05, p = 0.032; 95% CI 1.02, 1.09) and increased symptoms of wheeze (OR 0.7, p = 0.45; 95% CI 0.533, 0999). Forced vital capacity at 8 weeks was predictive of increased symptoms of wheeze (OR 0.005; p = 0.015; 95% CI 0.0060, 0.775). Conclusions: Postoperative changes in respiratory muscle strength and spirometry can persist up to at least 8 weeks postoperatively. Many patients report a change in respiratory symptoms of cough, phlegm, dyspnea, or wheeze. The change in respiratory symptoms at 8 weeks is correlated with residual respiratory muscle weakness, decrease in spirometry, and residual atelectasis.

Coronary artery bypass surgery is frequently complicated by postoperative atelectasis. Although routinely prescribed, the efficacy of any specific chest physical therapy is not well established. We studied patients at a university center undergoing elective coronary artery bypass surgery. Based upon chest X-ray criteria at extubation, patients (n = 228) were classified as demonstrating greater or lesser degrees of atelectasis. Those with a lesser degree of atelectasis were randomized to receive either early mobilization or sustained maximal inflations (SMI). Those with greater a degree of atelectasis were separately randomized to receive either SMI or single-handed percussions (SSP). We found the extent of atelectasis at extubation did not predict the risk of developing pneumonia. Hospital stays and intensive care unit stays were similar regardless of treatment. Physical therapy costs were highest in the most labor-intensive therapy group (SSP). We conclude that postoperative respiratory dysfunction is common but does not commonly cause significant morbidity or prolong hospital stay. Adding SMI to patients with minimal atelectasis at extubation does not improve clinical outcomes. Similarly, adding SSP to patients with marked atelectasis does not improve outcomes over those obtained with SMI and early ambulation.

To determine whether inclusion of a leukocyte specific filter into the extracorporeal circuit during aortocoronary bypass surgery alters postoperative cardiopulmonary function.Randomized, double-blinded control trial.Tertiary care hospital.Convenience sampling of patients undergoing elective aortocoronary bypass between October 1992 and June 1993.A total of 32 patients were randomized to a leukocyte specific filter (n = 16) or to a standard blood filter (n = 16) during the surgical procedure.White blood cell count in the standard filter group (12.2 +/- 3.6 10(9)/L) was higher (p = 0.047) than in the leukocyte filter group (9.9 +/- 2.6 10(9)/L) at 4 h postoperatively but counts were similar (p = 0.063) at 24 h (10.8 +/- 2.7 vs 8.9 +/- 2.6 10(9)/L, respectively). Leukocyte activation assessed by chemiluminescence was similar between groups at all measurement periods. We noted transient improvements (p0.05) in intrapulmonary shunt (19 +/- 50% vs 24 +/- 9%) and mean blood pressure (85 +/- 8 vs 76 +/- 9 mm Hg, respectively) in the leukocyte filter group compared with the standard filter group, respectively. Otherwise there were no differences noted between groups.Inclusion of a leukocyte filter during cardiopulmonary bypass caused transient cardiorespiratory improvement that was lost within 24 h and did not offer any significant clinical benefits.

The clinical, virological and pathological findings in 5 patients with neurological complications associated with rubella virus infection are described. The neurological illnesses began four to ten days after the rubella illnesses. The patients were all males aged between 6 and 17 years and were diagnosed during one non-epidemic year in a population of 1-5 million people. All the patients had rubella specific IgM in their sera. Two patients had no rash. In one of the patients who died, left internal carotid artery thrombosis and cerebral infarction were found at post-mortem. Rubella virus antigen and particles resembling rubella virus were found in the brain together with IgG and IgM in the same areas. This patient also had extensive liver necrosis. The other patient had a severe meningomyelitis and radiculitis and he recovered completely after two years. His serum rubella antibody rose significantly and was shown to leak into CSF during the acute stage of his illness. Three patients had a rash. Two of these patients had encephalitis: one recovered completely and the other had residual disability. The third patient had bilateral optic neuritis from which he recovered completely. Rubella specific IgM was, however, present in his serum for the abnormally long time of twenty-eight weeks indicating possible persistence of rubella virus.

Five patients with achalasia underwent limited myotomy without fundoplication. Surgery reduced mean lower esophageal sphincter resting pressure significantly (p less than .05) from 31 +/- 9.7 mm Hg to 16.1 +/- 8.2 mm Hg. Twenty-four-hour ambulatory esophageal pH studies demonstrated that the percentage of time the pH in the distal esophagus was below 4 was similar whether the patient was upright or supine (6.6 +/- 6.5% of total time upright vs. 9.1 +/- 12.7% of total time). Reflux events that occur in the supine position may be significant because of their prolonged duration resulting from the absence of normal secondary peristalsis in the body of the esophagus. Patients with achalasia who have undergone esophagomyotomy without fundoplication do not appear to experience more reflux than control subjects with normal esophageal function.

Chlamydia trachomatis was isolated from 35% of urethral swabs taken from 100 men with non-gonococcal urethritis (NGU). Eleven out of 53 female contacts of NGU (20.7%) were alsoC. trachomatis positive. In 21 female contacts ofC. trachomatis positive men, 9 (42.9%) wereC. trachomatis positive. All patients becameC. trachomatis negative folowing oxytetracycline therapy but 50% ofC. trachomatis positive and 47.6% ofC. trachomatis negative men required further treatment for symptoms and signs of urethritis.

Seven boys were studied who had the clinical features of subacute sclerosing panencephalitis (SSPE) and whose brain histology was consistent with SSPE. Measles antigen was detected in the seven brains by the direct fluorescent antibody method. Three out of the seven boys had in their sera measles specific immunoglobulin M (IgM) which was detected by the indirect fluorescent antibody method, and the cell receptors for it were acetone stable. A prozone effect was noted in the sera of two patients. The absorption of one patient's serum with Staphylococcus aureus to reduce the titre of immunoglobulin G (IgG) removed the prozone effect. Two of the boys who had high titres of measles specific IgM also had serum IgM which reacted with canine distemper virus antigen but the titres were eightfold lower. None of the boys had detectable rinderpest specific IgM in their sera.