No abstract

Between January 1, 1992, and January 23, 1996, 111 consecutive patients with severe left ventricular dysfunction underwent isolated coronary artery bypass grafting. The ejection fraction in these patients ranged from 10% to 34% (mean 27.9% +/- 5.4%); in 18 patients the value was less than 20%. The high operative mortality rate (7.6% in Society of Thoracic Surgeons database) in this group of patients at high risk was targeted for reduction by provision of, in addition to the usual inotropic support, progressively more intensive metabolic and mechanical support. The metabolic support consisted of triiodothyronine; glucose, insulin, and potassium; aspartate/glutamate in the cardioplegic solution; and warm-cold-warm/antegrade-retrograde-antegrade cardioplegia. Mechanical support included liberal use of the intraaortic balloon pump, use of a new occlusive retrograde cardioplegia catheter, ultrafiltration to remove myocardial depressant factors, and, finally, delayed sternal closure. The operative mortality rate was 1.8% (2/111). Complications included reoperation because of bleeding (3.6%, 4/111), mediastinitis (1.8%, 2/111), and stroke (0.9%, 1/111) and there were no occurrences of new postoperative acute renal failure (0.0%, 0/111). The intensive care unit stay was 2.2 +/- 0.9 days with a length of stay in the hospital of 13.7 +/- 22.1 days. These techniques done before operation, intraoperatively, and postoperatively optimize the milieu of the depressed left ventricle by maximizing perioperative high-energy phosphate bonds; increasing the effectiveness of inotropic agents; unloading the left ventricle by chemical, metabolic, and mechanical support; and removing known myocardial depressant factors, which reduced the operative mortality rate to 1.8% compared with 7.6% as reported in the Society of Thoracic Surgeons' database.

No abstract

Seventeen patients who underwent a cardiac operation developed a recurrent, symptomatic pleural effusion ultimately requiring video-assisted thoracic surgery (VATS) and talc pleurodesis. These patients represented 0.4% of all patients undergoing a cardiac operation over the same time period. Compared with an age- and sex-matched control group of cardiac surgery patients, patients requiring VATS for recurrent pleural effusion were more obese with higher body mass index (31.9 +/- 1.2 versus 28.3 +/- 1.4 kg/M2, P = 0.03), were more likely to have undergone a complex cardiac operation (8/17 versus 1/17, P =.01) and were more frequently on anticoagulation and antiplatelet agents besides aspirin (8/17 versus 2/17, P =.02). Patients underwent 1.86 +/- 0.34 thoracenteses with drainage of 846 +/- 166 mL/thoracentesis prior to referral for VATS. On average, patients underwent VATS 4.83 +/- 1.49 months after their cardiac operation. There were 3 VATS-related complications (17.6%) and no deaths. VATS talc pleurodesis led to symptomatic and radiologic improvement in all patients with a mean follow-up of 8.2 +/- 1.5 months. VATS talc pleurodesis effectively and safely treats the unusual postcardiac surgery patient with refractory pleural effusion.

No abstract