RESUMEN
Prevention of perioperative cerebrovascular injury in patients undergoing open heart surgery is a serious task for the surgeon, especially as age and severity of atherosclerotic disease increases. The most significant predisposing factors have been identified as existing carotid arterial disease or prior stroke, heavy calcification of the aorta, renal dysfunction, advanced age, and diabetes mellitus. We have studied a series of 600 open heart patients from 1992 to 1995 from the incidence of peri-operative stroke and mortality, evaluating 16 risk factors: heavy calcification of the ascending aorta, asymptomatic carotid disease, insulin-dependent diabetes mellitus, prior CVA, left ventricular function (ejection fraction of 20% or less), age greater than 70, renal dysfunction, transmural myocardial infarction, fluid balance index greater than 2500 ccs, smoking, type of procedure, emergency procedure, non-insulin-dependent diabetes mellitus, cardiopulmonary bypass time, gender, and hypertension Stroke occurred in 8 patients (1.3%), one of whom die postoperatively. Full or near-full recovery was experienced by 5 patients; 2 patients remained partially dysfunctional at the end of the study period. The operative mortality was 2.0% (12 patients); 10 deaths occurred in hospital and 2 following discharge within 30 days postoperatively. The risk of stroke was 15 times greater in patients over age 70; 16 times greater in older males (> or = 70 years); 5 times greater in patients with prior stroke or existing (asymptomatic) carotid artery disease; 8 times greater in patients with renal dysfunction; 4 times greater with a positive fluid balance index; and twice greater when cardiopulmonary bypass exceeded 110 minutes. Four of the stroke patients had diabetes mellitus. Two of 9 patients with heavy calcification of the aortic arch suffered cerebrovascular injury. Six or more of the risk factors studied were present in 81 patients; all 8 stroke patients (9.9%) came from this subgroup. The study suggests the importance of pre-operative evaluation of cerebrovascular atherosclerotic disease and the minimal manipulation ("minimal touch" technique) of a calcific aortic arch.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Trastornos Cerebrovasculares/prevención & control , Cardiopatías/cirugía , Complicaciones Posoperatorias/prevención & control , Factores de Edad , Anciano , Enfermedades de la Aorta/complicaciones , Calcinosis/complicaciones , Enfermedades de las Arterias Carótidas/complicaciones , Trastornos Cerebrovasculares/epidemiología , Trastornos Cerebrovasculares/etiología , Diabetes Mellitus Tipo 1/complicaciones , Femenino , Humanos , Enfermedades Renales/complicaciones , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Factores de Riesgo , Factores SexualesRESUMEN
Reported are two cases of benign endobronchial lesions with granulomatous reactions that led to complete airway obstruction. Combined with a long history of cigarette smoking and the appearance of a hilar mass, these lesions appeared clinically to be bronchogenic carcinomas. Both cases went to thoracotomy, but in each case the requirement that malignant tissue be identified, allowed recognition of a foreign body in one case, and broncholith in the second, avoiding pneumonectomy in both cases.
Asunto(s)
Bronquios , Carcinoma Broncogénico/diagnóstico , Cuerpos Extraños/diagnóstico , Neoplasias Pulmonares/diagnóstico , Anciano , Broncoscopía , Diagnóstico Diferencial , Cuerpos Extraños/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Radiografía Torácica , Tomografía Computarizada por Rayos XRESUMEN
Tension pneumopericardium is a rare entity typically described in premature infants requiring positive-pressure ventilation. However, recent reports suggest an increase in its occurrence in adults. A case of delayed postoperative tension pneumopericardium in an adult patient is presented with a review of the history, pathophysiology, presentation, and treatment of this entity.
Asunto(s)
Lesión Pulmonar , Pulmón/cirugía , Neumoperitoneo/etiología , Traumatismos Torácicos/cirugía , Toracotomía/efectos adversos , Heridas por Arma de Fuego/cirugía , Adulto , Resultado Fatal , Hemotórax/etiología , Humanos , Masculino , Síndrome de Dificultad Respiratoria/etiologíaRESUMEN
The aim of this study was to evaluate the hemodynamic effects of extraaortic counterpulsation with a latissimus dorsi (LD) neurovascular flap in a canine heart failure model. Five dogs (8-18 kg) had a left LD neurovascular muscle flap raised. The muscle was brought into the chest through the second interspace and wrapped around the aorta. Parameters studied were heart rate (HR), systolic pressure (SP), diastolic pressure (DP) pulmonary artery pressure (PAP), mixed venous oxygen saturation (MVO2), and cardiac output (CO). Baseline measurements were obtained with the muscle nonstimulated and stimulated by a prototype burst stimulation. The only parameter that changed significantly with muscle stimulation was DP (55.8 +/- 3.8 mmHg to 72.4 +/- 4.8 mmHg, p less than 0.05). Propranolol (3-4 mg/kg) and verapamil (2-3 mg) were given intravenously to induce heart failure. Mean blood pressure decreased from 64.12 +/- 5.03 mmHg to 43.3 +/- 9.28 mmHg (p less than 0.05). Repeat measurements were obtained. With stimulation of the muscle flap there was an increase in DP from 36.8 +/- 9.2 mmHg to 55.4 +/- 19.3 mmHg (p less than 0.05). Although CO increased from 8% to 18% in all animals (1.42 +/- 0.33 L/mm to 1.58 +/- 0.34 L/mm) this did not reach statistical significance. This data indicates that both DP and CO can be improved by this method of cardiac assist in a heart failure model.