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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The effect of the calcium channel blocker, diltiazem, on cardiac performance was examined in 90 patients who underwent isolated aortic valve replacement for aortic valve diseases with marked left ventricular hypertrophy. The patients were randomly assigned to one of five groups dependent on the treatment plan with diltiazem: group 1, 5-day preoperative treatment with oral administration of 60 mg diltiazem 3 times daily, 10 mg diltiazem intravenously as a bolus dose before the beginning of the cardiopulmonary bypass, and 5 mg diltiazem intravenously 10 min before removal of aortic clamp; group 2, 5-day preoperative treatment with oral administration of 60 mg diltiazem 3 times daily; group 3, 10 mg diltiazem intravenously as a bolus dose before the beginning of CPB and 5 mg 10 min before removal of the aortic clamp; group 4, 15 mg diltiazem in 1000 ml cardioplegic solution, given as additive; group 5, control group not receiving diltiazem. All operative procedures were performed in an identical manner with an average cross-clamping time of 57.7 min and cooling the heart down to 16 degrees-17 degrees septal temperature by perfusion of the coronary arteries with 4 degrees C cold cardioplegic solution. In each patient the heart rate (HR), cardiac output and cardiac index (CO, CI), stroke volume index (SVI), left ventricular stroke work index (LVSWI) and systemic vascular resistance index (SVRI) were recorded and calculated before and after the ischemic period. Transmural samples were obtained three times by needle biopsy technique from the anterior free wall of the heart. Analysis of the variables revealed that: (1) complete cessation of electromechanical activity was achieved significantly more rapidly in groups 1 and 3 than in the other groups; (2) recovery of sinus rhythm and function of the conductive system required significantly longer in groups 1 and 3; (3) the time-related values of the important hemodynamic factors (CO, CI, LWSVI and SVRI) showed a significantly more effective postperfusion cardiac performance in groups 1 and 3 than in groups 2, 4 and 5. An oral dose of 180 mg diltiazem for 5 to 7 days preoperatively in combination with intravenous administration of 10 mg before the beginning of CPB and 5-10 mg during reperfusion can be recommended in patients undergoing open-heart surgery for isolated aortic valve diseases and left ventricular hypertrophy.
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PMID:Perioperative myocardial protection with the calcium antagonist diltiazem. 161 May 90

From January 1, 1988 to September 30, 1993, 44 of 2,455 patients undergoing cardiac surgery for acquired heart disease at our institution sustained an intraoperative or postoperative cerebrovascular accident (CVA). Demographic data, atherosclerosis risk factors, past medical history, cardiac catheterization reports, and intraoperative findings were retrospectively reviewed. The highest rate of CVA was in the sub-group of patients undergoing simultaneous myocardial revascularization and carotid endarterectomy (18.2%). The lowest rate was in a group of patients who underwent aortic valve replacement (0.9%). Severe aortic arch atherosclerosis with the presence of atheromatous material or calcinosis at the cannulation site was identified intraoperatively in 43.2% of patients with neurological complications and in 5% of the group without CVA (x2 = 18.1, p = 0.0001). Of 44 patients with CVA, 13.6% had a history of preoperative completed stroke. CPB time was 90.1 +/- 4.9 min vs. 71.6 +/- 3.7 min (p = 0.004), and aortic cross-clamping time was 54.5 +/- 3.2 min compared to 39.8 +/- 2.7 min (p = 0.001) in groups with and without postoperative stroke, respectively. Hypertension was an independent risk factor of postoperative CVA (x2 = 9.5, p = 0.02), but age was not. Neurological complications correlated with high operative mortality (38.6%) and prolonged postoperative hospital stays (35.1 +/- 5.3). These data describe predictors for the development of post-cardiopulmonary bypass CVA and identify a high-risk subgroup for neurological events. The preoperative recognition of risk factors is an essential step toward the reduction of morbidity and mortality.
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PMID:Predictors of stroke after cardiac surgery. 754 91

All available controlled studies of warm versus cold and antegrade versus retrograde delivery of cardioplegia were reviewed to assess the incidence of perioperative stroke and adverse neuropsychological outcomes. Nine randomized trials and substudies and two studies with immediate historical consecutive controls reported neurological outcomes and were described as warm versus cold. Pooled event rates for perioperative stroke were 1.5% for warm antegrade, 3.14% for warm retrograde, 1.7% for cold antegrade, and 0% to 1.2% for cold retrograde. Examining within trial differences, only one study showed a significant disadvantage to warm 4.5% versus cold 1.4% on incidence of perioperative stroke, but the design does not permit determination of whether the difference is due to systemic temperature, retrograde coronary perfusion, or other factors. Furthermore, if only warm (> 33 degrees C) versus cold (< 30 degrees C) systemic perfusion is examined in all studies for the incidence of stroke irrespective of cardioplegia temperature or antegrade versus retrograde coronary perfusion (warm 2.1%; cold 1.6%), the above study remains a significant outlier. This suggests that the differences found are unlikely to be due to temperature but may be related to antegrade versus retrograde coronary perfusion. Review of randomized trials evaluating neuropsychological function post-cardiopulmonary bypass (post-CPB) also failed to reveal any advantage related to temperature of systemic perfusion. Since manipulations that are most likely to give rise to cerebral embolization are uniformly carried out at normothermia at the beginning and end of the operation, it is not entirely unexpected that the incidence of neurological events was found to be independent of the temperature of CPB.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Neurological outcomes and cardiopulmonary temperature: a clinical review. 757 45

Total intravenous anesthesia (TIVA) using alfentanil and propofol was used in 10 patients undergoing coronary artery bypass grafting. In an attempt to diminish unwanted side effects, lower doses were chosen than if either drug had been used alone. Anesthesia was induced with alfentanil, 75 micrograms/kg, followed by a sleep dose of propofol (mean dose 0.5 mg/kg). Maintenance in the precardiopulmonary bypass (CPB) period was achieved by infusions of propofol (6 mg/kg/h) and alfentanil (100 micrograms/kg/h). These were decreased by two thirds on commencement of CPB, and increased to half the initial rate on rewarming to 32 degrees C. Additional boluses of alfentanil were used to control breakthrough hypertension. The mean arterial pressure (MAP) and left ventricular stroke work index (LVSWI) fell significantly on induction. MAP but not LVSWI returned to baseline levels at skin incision. The cardiac index (CI) was maintained. A degree of myocardial depression was suggested by a fall in LVSWI despite maintaining preload, and by the failure of CI to increase in the presence of a reduced SVR. Anesthesia was satisfactory in all but one patient who developed breakthrough hypertension on sternotomy with transient ST segment depression, and awareness after CPB despite a plasma alfentanil concentration of 450 ng/mL. Mean time to wakening was 55 minutes. The study indicated that TIVA using propofol and alfentanil in the dosages described provides satisfactory basal anesthesia for coronary artery bypass surgery in patients with good left ventricular function, but requires additional pharmacologic manipulation, particularly with boluses of alfentanil, to control breakthrough hypertension.
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PMID:Total intravenous anesthesia using propofol and alfentanil for coronary artery bypass surgery. 806 Dec 61

Plasma concentrations and hemodynamic effects of olprinone were evaluated in seventeen patients undergoing open heart surgery. The patients were randomized into the bolus group (15 micrograms.kg-1 bolus dose +0.1 microgram.kg-1.min-1 infusion, n = 9) and the non-bolus group (0.1 microgram.kg-1.min-1 infusion, n = 8). Plasma concentrations and hemodynamic variables were measured before CPB (cardiopulmonary bypass; baseline), 5, 60 min after weaning from CPB, and 3, 6 hours after the end of surgery. Plasma concentrations in the non-bolus group were significantly lower than those of bolus group at any point except for 3 hours after the end of surgery. In the bolus group, increases in the cardiac index and stroke volume index were significantly higher compared with the non-bolus group. From these results we conclude that olprinone given in bolus (15 micrograms.kg-1) followed by continuous infusion (0.1 microgram.kg-1.min-1) is efficacious and safe during weaning from CPB.
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PMID:[The effect of olprinone administered after cardio-pulmonary bypass during open heart surgery, evaluated by its plasma concentrations and hemodynamic changes]. 1055 99

Every acute dissection involving the ascending aorta (Stanford type A) must undergo emergency surgical repair. However, the surgical techniques must vary according to the clinical presentation of the patients or the anatomical patterns observed. Furthermore, surgery is generally difficult because of the poor condition of the aortic tissues. To reduce those difficulties many technical artifacts have been described. In 1977, we proposed the use of gelatin-resorcin-formalin (GRF) biological glue to reinforce the suture areas. From January 1977 to July 1999, 212 patients (pts) (152 males and 60 females) aged from 15 to 80 years (mean age: 54 +/- 11 years) underwent an emergency operation for type A aortic dissection. One-hundred-seventy-eight pts (84%) were operated on within 4 hours after being referred to the hospital. Twenty-eight pts (13.2%) had Marfan's syndrome. In 44 patients (20.7%), the aortic valve was replaced either independently (6 cases--2.8%) or by means of a composite graft (38 cases--17.9%). Because of the location of the intimal tear, the aortic replacement was extended to the transverse arch in 61 pts (28.7%). Hospital mortality amounts to 21.6% (46 pts), 25% in pts with arch replacement and 19.4% in pts without arch replacement (n.s). Analysis of hospital mortality demonstrates that the main causes of death were cardiac tamponade, neurologic disorders and visceral malperfusion. One-hundred-sixty-six pts were discharged and surveyed from 5 months to 22 years postoperatively (mean follow-up: 85 +/- 66 months). During this period of time, 25 pts (15%) had to be reoperated for a total of 33 reoperations. Seven pts (28%) died at reoperation. Using univariate analysis, the presence of Marfan's syndrome (p < 0.05) and absence of arch replacement (p < 0.02) were determinant risk factors for reoperation. Emergency (p < 0.01) and thoraco-abdominal replacement (p < 0.04) were determinant riskfactors for death at reoperation. The freedom from reoperation (Kaplan-Meier, CI: 95%) is 96% (90-98), 87% (79-92), 80% (70-88), 66% (51-78) at 1, 5, 10 and 15 years respectively. A total of 39 pts (24.3%) died during follow-up. The presence of Marfan's syndrome (p < 0.01), reoperation (p < 0.02), stroke (p < 0.05), and cardiac failure (p < 0.05) were determinant risk factors of late mortality. The late survival rate (K-M. C.I.: 95%), including hospital mortality, is 71% (64-77), 66% (58-73), 56% (47-64), 46% (36-56), 37% (28-44) at 1, 10, 15 and 20 years, respectively. From our experience extending over more than 23 years, GRF glue has proved to be extremely useful, making the procedure much easier and safer. Nevertheless, many factors are of importance in the pre-, intra- and postoperative management of the patients. Cardiac tamponade and visceral malperfusion must be properly diagnosed and treated. During aortic repair, the main intimal tear must be resected. The transverse arch must be checked and replaced whenever necessary. The aortic valve should be preserved whenever possible. During CPB, perfusing the aorta in the regular antegrade manner seems to dramatically reduce the rate of malperfusion. The quality of the first emergency operation seems to have a major influence on the late results, especially concerning the rate of late reoperations and aortic ruptures. However, those late results depend also on the patient's basic condition, particularly in Marfan patients.
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PMID:Surgery of acute type A dissection: what have we learned during the past 25 years? 1109 59

To investigate the influence of hypothermic cardiopulmonary bypass (HCPB) at 25 degrees C and circulatory arrest at 18 degrees C on the global and regional cerebral blood flow (CBF) during pulsatile perfusion, we performed the following studies in a neonatal piglet model. Using a pediatric physiologic pulsatile pump, we subjected six piglets to deep hypothermic circulatory arrest (DHCA) and six other piglets to HCPB. The DHCA group underwent hypothermia for 25 min, DHCA for 60min, cold reperfusion for 10 min, and rewarming for 40 min. The HCPB group underwent 15 min of cooling, followed by 60 min of HCPB, 10min of cold reperfusion, and 30 min of rewarming. The following variables remained constant in both groups: pump flow (150 ml/kg/min), pump rate (150 bpm), and stroke volume (1 ml/kg). During the 60-min aortic crossclamp period, the temperature was kept at 18 degrees C for DHCA and at 25 degrees C for HCPB. The global and regional CBF (ml/100g/min) was assessed with radiolabeled microspheres. The CBF was 48% lower during deep hypothermia at 18degrees C (before DHCA) than during hypothermia at 25 degrees C (55.2 +/- 14.3ml/100g/min vs 106.4 +/- 19.7 ml/100 g/min; p < 0.05). After rewarming, the global CBF was 45% lower in the DHCA group than in the HCPB group 48.3 +/- 18.1 ml/100g/min vs (87 +/- 35.9ml/100g/min; p < 0.05). Fifteen minutes after the termination of CPB, the global CBF was only 25% lower in the DHCA group than in the HCPB group (42.2 +/- 20.7 ml/100 g/min vs 56.4 +/- 25.8ml/100g/min; p = NS). In the right and left hemispheres, cerebellum, basal ganglia, and brain stem, blood flow resembled the global CBF. In conclusion, both HCPB and DHCA significantly decrease the regional and global CBF during CPB. Unlike HCPB, DHCA has a continued negative impact on the CBF after rewarming. However, 15 min after the end of CPB, there are no significant intergroup differences in the CBF.
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PMID:Global and regional cerebral blood flow in neonatal piglets undergoing pulsatile cardiopulmonary bypass with continuous perfusion at 25 degrees C and circulatory arrest at 18 degrees C. 1176 Oct 90

This report shows a new spectrum of applications of a concept of brain protection for the cardiothoracic surgeon. The underlying treatment deals with an ischemic/reperfusion injury, and novel applications of principles well known in cardiac surgery will be used to provide brain protection. Unique opportunities arise from the uncommon use of circulatory arrest in infants and adults (1-2% of procedures) to the larger areas of sudden death (450,000 pts/year in the US), stroke (700,000 pts/year) and carotid occlusion for peri-operative endarterectomy, and neurologic problems after CPB (30% incidence). Treatment pathways in sudden death will address the brain during CPR, the body to get a cause of arrest with use of peripheral CPB, and a controlled cardiac reperfusate to correct the underlying lesion. Circulatory arrest provides the model to treat, both this uncommon surgical process, with extension as toward treating stroke with controlled reperfusion. Novel models of pretreatment and warm brain reperfusion, that mimic warm heart reperfusion are suggested. Construction of the ultimate brain reperfusate, and its conditions of delivery will follow the valid and tested development phases of a warm cardioplegic solution, but become directed towards the brain. Old tricks that lead to new goals will become our innovative vantage points.
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PMID:Stroke and extra-cardiac perfusion: new vantage points in brain protection. 1577 54

Between May 1997 and November 2002, 68 patients with one or two-vessel disease (55+/-9 years) underwent Port Access CABG using the Heartport endoCPB. The LITA was used in 63 cases, the RITA in 14, a radial artery in 2 and a vein graft in 3. Mean distal anastomoses was 1.3+/-0.5. Cross clamping, CPB, and operative times were 42+/-20 min, 64+/-27 min, and 3.8+/-1.5 h. Postoperative ventilation was 11+/-17 h, and ICU stay was 1.9+/-2.6 days. At day-1, troponin level was 2.3+/-2.9 UI and blood loss was 398+/-240 ml. Two patients needed long intubation and two had pleural re-drainage. One patient had a stroke, one had a myocardial infarction, and one underwent revision for bleeding. Hospital stay was 7+/-3 days. 65% were discharged to home. Follow up was completed in all cases (4.1+/-1.8 years). CCS score was significantly reduced (from 3.1+/-0.3 to 1.1+/-0.3, P<0.0001). Two patients had PTCA and stenting of non-grafted arteries. Five other patients had recurrent angina. Angiograms showed patent grafts in all cases. Two patients died after 19 months and 5 years from non cardiac reasons. In conclusion, Port Access CABG remains a safe technique with stable results at mid-term follow up.
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PMID:Which place for Port Access surgery in coronary artery bypass grafting? A mid-term follow up study. 1767 May 17

Traumatic great vessel injuries are frequently lethal events. Expedient diagnosis and prompt repair by clamping and replacing the affected segment of aorta (often with left-heart bypass) can salvage many patients. Rarely, due to the location of the injury or delayed presentation, standard techniques cannot be used and hypothermic circulatory arrest (HCA) is required for access, exposure and repair. The results of surgical reconstruction of acute and chronic traumatic thoracic vascular injuries under these circumstances are not well described. We reviewed all operations on the great vessels at our institution over a 16-year period that had a traumatic etiology and used HCA. Fourteen cases were identified (10 male, 4 female, age 46+/-4 years), arising from three acute and eleven remote traumatic events. All repairs were performed with cardiopulmonary bypass (mean CPB time was 155+/-13 min), deep hypothermia, and an interval of circulatory arrest (mean circulatory arrest interval 31+/-4 min). One patient died in the perioperative period from a stroke (7% 30-day mortality). Another patient exsanguinated from a recurrent pseudoaneurysm 3 months post-repair. No patient developed paraplegia. HCA can be a useful adjunct in managing complex post-traumatic great vessel injuries. Acute injuries of the ascending aorta and transverse arch usually require this technique, but HCA also offers a safe way to manage repair of the descending thoracic aorta when proximal aortic control is compromised.
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PMID:Hypothermic circulatory arrest for repair of injuries of the thoracic aorta and great vessels. 1767 Jun 46


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