RESUMEN
BACKGROUND: Rupture of the ascending aorta caused by blunt trauma rarely has been diagnosed and treated. As a result, the clinical manifestations and management of this injury have not been clearly defined. METHODS: We describe the clinical presentation, diagnosis, and management of 3 consecutive patients with ascending aortic rupture treated during the last 3 years. We also review the cases with this injury reported in the English-language literature until 1996. RESULTS: The predominant clinical manifestations of all patients, including reviewed case reports, were those of other organ injuries, and 5 had signs of aortic regurgitation and 1 of cardiac tamponade. The mediastinal silhouette was normal in 6 and widened in 14 patients, 1 of whom had also rupture of the subclavian artery. The aortic tears were managed with primary repair or with graft interposition and the valve injury with replacement or repair. Three of 20 patients died, for an overall mortality of 15%. CONCLUSIONS: Ascending aortic rupture should be considered in any patient with severe blunt trauma who has widened mediastinum or cardiac tamponade, as well as in patients with associated major thoracic injuries. Absence of a widened mediastinal silhouette does not exclude the diagnosis. The repair is relatively straightforward, but survival depends primarily on the severity of associated injuries.
Asunto(s)
Aorta/lesiones , Rotura de la Aorta/etiología , Heridas no Penetrantes/complicaciones , Adulto , Aorta/cirugía , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/cirugía , Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/etiología , Aortografía , Implantación de Prótesis Vascular , Taponamiento Cardíaco/etiología , Resultado Fatal , Femenino , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Mediastino/diagnóstico por imagen , Persona de Mediana Edad , Traumatismo Múltiple , Tasa de Supervivencia , Traumatismos Torácicos/complicacionesRESUMEN
BACKGROUND: Aminooleic acid treatment has been demonstrated to prevent porcine valve calcification and to protect valvular hemodynamic function. Initial enthusiasm was tempered by histologic studies of these AOA valves, which showed cuspal hematomas, structural loosening, and surface roughening. This prompted a systematic review of the AOA treatment process. Unsolubilized particles of alpha aminooleic acid present in the treatment solution were identified as the cause of mechanical abrasion of valve cusps during processing. These particles were eliminated with a revamped protocol, which included filtration of the AOA solution before valve preparation. METHODS: Porcine aortic valve cusps treated with this modified AOA protocol (AOA II) were studied in a rat subdermal implant model of mineralization. A juvenile sheep trial was then used to confirm the antimineralization effects of AOA II on glutaraldehyde-fixed porcine aortic roots in a circulatory model of accelerated calcification. RESULTS: Retrieved AOA II-treated cusps from the subdermal model were markedly less calcified than control cusps (AOA II, 1 +/- 0, 17 +/- 4, 23 +/- 6, and 17 +/- 10 versus control, 189 +/- 14, 251 +/- 16, 250 +/- 14, and 265 +/- 10 mg calcium/mg sample at 4, 8, 12, and 16 weeks, respectively; p < 0.0001). Morphologic examination of the AOA II cusps of the valves retrieved from the sheep demonstrated freedom from the structural loosening, surface roughening, and hematoma formation that had limited the utility of the original AOA preparation technique. Cusps from AOA II-treated porcine roots had significantly less calcium than control cusps (AOA II, 5.5 +/- 3.0 mg/g; control, 91.2 +/- 19.5 mg/g; p = 0.0004). The aortic walls had similar levels of calcification (AOA II, 156 +/- 73 mg/g; control, 159 +/- 10 mg/g; p = not significant). CONCLUSIONS: These data suggest that the modified AOA technique warrants further evaluation as an antimineralization treatment for glutaraldehyde-fixed porcine bioprostheses.
Asunto(s)
Bioprótesis , Calcinosis/prevención & control , Prótesis Valvulares Cardíacas , Ácidos Oléicos , Complicaciones Posoperatorias/prevención & control , Animales , Masculino , Modelos Biológicos , Ácidos Oléicos/uso terapéutico , Ratas , Ratas Sprague-Dawley , OvinosRESUMEN
A case of severe unilateral bullous emphysema in an otherwise healthy young man is presented to highlight a rare histologic variant termed "placental transmogrification of the lung." The etiology is unknown, but operation has been curative in the small number of cases reported.
Asunto(s)
Pulmón/patología , Enfisema Pulmonar/patología , Adulto , Humanos , Pulmón/diagnóstico por imagen , Masculino , Placenta , Neumonectomía , Enfisema Pulmonar/diagnóstico por imagen , Enfisema Pulmonar/fisiopatología , Enfisema Pulmonar/cirugía , Radiografía , Pruebas de Función RespiratoriaRESUMEN
Massive pulmonary air leak from a ruptured bleb in a patient with emphysema may be uncontrollable by the usual methods. A technique is illustrated where fibrin glue, cyanoacrylate glue, and a bovine pericardial patch are used in combination to seal the leak.
Asunto(s)
Cianoacrilatos/uso terapéutico , Neumonectomía , Complicaciones Posoperatorias/terapia , Enfisema Pulmonar/cirugía , Humanos , Prótesis e ImplantesRESUMEN
An increasing body of evidence suggests that the majority of myocardial injury that occurs during ischemia and reperfusion is effected during the reperfusion phase. There is also convincing evidence that controlling the conditions of reperfusion and composition of the reperfusate can markedly minimize the ultimate injury following an ischemic insult. Medical reperfusion (PTCA, thrombolytics) has the disadvantage of reperfusing with unmodified whole blood under uncontrolled conditions, whereas surgical reperfusion allows very stringent control of both. A brief review of the pathophysiology of ischemia and reperfusion is presented to gain insight into the mechanisms of injury that can be counteracted by controlling the conditions of reperfusion and composition of the reperfusate. Surgical protocols that have been developed independently at two separate institutions are outlined, along with the experimental data supporting each method, and the advantages and disadvantages of each method. This information should allow implementation of a rational plan of myocardial protection for resuscitation of the ischemic myocardium when performing coronary artery bypass grafting in the setting of acute myocardial ischemia and infarction.
Asunto(s)
Puente de Arteria Coronaria , Infarto del Miocardio/cirugía , Daño por Reperfusión Miocárdica/prevención & control , Reperfusión Miocárdica/métodos , Protocolos Clínicos , Humanos , Infarto del Miocardio/fisiopatologíaRESUMEN
Continuous retrograde warm blood cardioplegia was compared with two widely used hypothermic myocardial protection techniques in a canine model of acute regional myocardial ischemia with subsequent revascularization. Animals (n = 30) underwent 45 minutes of left anterior descending coronary artery occlusion then cardioplegic arrest (60 minutes), followed by separation from cardiopulmonary bypass and data collection. The cold oxygenated crystalloid cardioplegia group (CC; n = 8) and the cold blood cardioplegia group (CC; n = 10) had cardiopulmonary bypass at 28 degrees C, antegrade arrest, and intermittent retrograde delivery. The warm blood cardioplegia group (WB; n = 12) had normothermic cardiopulmonary bypass, antegrade arrest, and continuous retrograde delivery. Overall ventricular function (preload recruitable stroke work relationship; ergs x 10(3)/mL) was significantly (p < 0.001) better for WB (WB, 80 +/- 11; CB, 67 +/- 13; CC, 57 +/- 12). Systolic function (maximum elastance relationship; mm Hg/mL) was also significantly (p < 0.001) better for WB (WB, 11.6 +/- 3.6; CB, 8.6 +/- 2.7; CC, 6.2 +/- 1.3). Diastolic function (stress-strain relationship; dynes x 10(3)/cm2) revealed significantly (p < 0.001) decreased compliance for CC (WB, 20 +/- 6; CB, 19 +/- 7; CC, 27 +/- 11). Left anterior descending coronary artery regional adenosine triphosphate/adenosine diphosphate ratios were significantly (p = 0.02) worse for CC (WB, 10.2 +/- 2.3; CB, 9.4 +/- 2.6; CC, 5.6 +/- 1.5). Myocardial edema significantly (p = 0.03) increased over time only in the CC animals (WB, 0.4% +/- 2.3%; CB, -0.3% +/- 3.6%; CC, 5.5% +/- 2.3%). In this model of acute regional myocardial ischemia and revascularization, continuous retrograde warm aerobic blood cardioplegia provided superior myocardial protection compared with cold oxygenated crystalloid cardioplegia with intermediate results for cold blood cardioplegia.
Asunto(s)
Paro Cardíaco Inducido/métodos , Infarto del Miocardio/terapia , Adenosina Trifosfato/metabolismo , Animales , Cardiomiopatías/etiología , Diástole/fisiología , Perros , Edema/etiología , Paro Cardíaco Inducido/efectos adversos , Hemodinámica/fisiología , Calor , Hipotermia Inducida/métodos , Infarto del Miocardio/fisiopatología , Revascularización Miocárdica , Miocardio/metabolismo , Estrés Fisiológico/fisiopatología , Función Ventricular Izquierda/fisiologíaRESUMEN
Three myocardial protection techniques were studied in a canine model of acute myocardial ischemia with subsequent revascularization. Eighteen animals were randomly assigned to one of three treatment regimens: cold oxygenated crystalloid cardioplegia (CC), cold blood cardioplegia with modified reperfusate (CB), and continuous aerobic warm blood cardioplegia (WB) (n = 6 per group). Systemic hypothermic cardiopulmonary bypass (28 degrees C), antegrade arrest, and intermittent retrograde and antegrade delivery were used for the CC and CB groups. Systemic normothermic cardiopulmonary bypass, antegrade arrest, and continuous retrograde delivery were used for the WB group. Fifteen minutes of warm global ischemia was followed by occlusion of the left anterior descending coronary artery (15-minute duration) and simultaneous initiation of cardioplegic arrest (60-minute duration) to simulate clinical revascularization. After reperfusion, the animals were separated from cardiopulmonary bypass. Myocardial function, electrocardiogram, myocardial energetics, water content, histopathology, and defibrillation requirements were compared between groups. There was no significant difference in maximum elastance, myocardial oxygen consumption, myocardial edema, or histopathologic evidence of injury between groups. However, overall ventricular function, assessed by the slope of the preload recruitable stroke work relationship, was significantly better for the WB group (p = 0.04) (WB, 73 +/- 9; CB, 56 +/- 7; CC, 47 +/- 5). Diastolic function as assessed by the slope of the stress-strain relationship was significantly worse overall for the cold groups (p = 0.001) (WB, 20 +/- 2.2; CB, 39 +/- 1.3; CC, 37 +/- 3.1). Myocardial injury as assessed by ST segment elevation (millimeters) was less for the WB group (p = 0.03) (WB, 0.4 +/- 0.3; CB, 1.7 +/- 0.2; CC, 1.6 +/- 0.7). Countershocks necessary to restore sinus rhythm after cross-clamp removal were fewer in the WB group (p = 0.03) (WB, 0.8 +/- 0.3; CB, 4.0 +/- 1.2; CC, 5.5 +/- 1.5). In this model of acute global myocardial ischemia, continuous aerobic warm blood cardioplegia has important advantages over two widely used clinical hypothermic protection techniques.