Innominate artery dissection due to selective cerebral antegrade perfusion.

We present the first case of successfully treated innominate artery dissection as a complication of selective cerebral antegrade perfusion during reoperative aortic valve and hemiarch replacements. Innominate artery dissection was suspected based on unilateral decreases in the right radial arterial pressure and right cerebral oximetry value. Intraoperative ultrasonography demonstrated minimal flow in the right internal carotid.

Variation in local institutional review board evaluations of a multicenter patient safety study.

Several highly visible quality improvement (QI) projects led to controversy over their ethical oversight, attracting attention from institutional review boards (IRBs) and the Office for Human Research Protection. While QI research has increased dramatically, there is limited empirical evidence regarding how multiple IRBs review the same study. This paper describes the variations in local IRB reviews for the same a multicenter QI study.

Case report: separation from cardiopulmonary bypass with a rigid bronchoscope airway after hemoptysis and bronchial impaction with clot.

Hemoptysis after cardiopulmonary bypass (CPB) occasionally occurs, and has varying clinical significance based upon amount of bleeding. Hemoptysis resulting in a clot and airway obstruction is an extremely rare event found almost exclusively in the intensive care unit. We describe a unique case of hemoptysis resulting in bronchial impaction from a clot requiring an emergent return to CPB during valve replacement surgery.

Comparison of image quality between a narrow caliber transesophageal echocardiographic probe and the standard size probe during intraoperative evaluation.

Background: Transesophageal echocardiography (TEE) has become an integral part of the evaluation and monitoring of patients during cardiac operation. Until recently, the smallest TEE probe with multiplane imaging measured 13 mm in diameter. This size is now standard for adult TEE probes.

Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease.

Objective: Atheromatous aortic disease is a risk factor for excessive mortality and stroke in patients undergoing coronary artery bypass grafting. Outcomes of off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass in patients with severe atheromatous aortic disease were compared by propensity case-match methods.

Methods: Routine intraoperative transesophageal echocardiography identified 985 patients undergoing isolated coronary artery bypass grafting with severe atheromatous disease in the aortic arch or ascending aorta.

Off-pump coronary artery bypass grafting reduces mortality and stroke in patients with atheromatous aortas: a case control study.

Background: Patients with severe atheromatous aortic disease (AAD) who undergo coronary artery bypass (CABG) have an increased risk of death and stroke. We hypothesized that in these high risk patients, off-pump coronary artery bypass (OPCAB) technique is associated with lower morbidity and mortality.

Methods And Results: Between June 1993 and January 2002, 5737 patients undergoing CABG had routine intra-operative TEE with 913 (15.

Routine intraoperative transesophageal echocardiography identifies patients with atheromatous aortas: impact on "off-pump" coronary artery bypass and perioperative stroke.

Background: Patients with severe atheromatous aortic disease (AAD) undergoing coronary artery bypass grafting (CABG) have increased operative risks. The "off-pump" CABG (OPCAB) technique was evaluated in patients given the diagnosis of severe AAD by routine transesophageal echocardiography.

Methods: A total of 5737 patients underwent CABG, with 913 having transesophageal echocardiography findings of severe AAD.

Minimally invasive mitral valve surgery: a 6-year experience with 714 patients.

Background: This study analyzes a single institutional experience with minimally invasive mitral valve operations of 6 years, reviewing short-term morbidity and mortality and long-term echocardiographic follow-up data.

Methods: Seven hundred fourteen consecutive patients had minimally invasive mitral valve procedures between November 1995 and November 2001; concomitant procedures included 91 multiple valves and 18 coronary artery bypass grafts. Of these 714 patients, 561 patients had isolated mitral valve operations (375 repairs, 186 replacements).

Protruding aortic arch atheromas: risk of stroke during heart surgery with and without aortic arch endarterectomy.

Background: Stroke occurs in 1% to 7% of heart surgery. Aortic arch atherosclerosis is a risk factor for intraoperative stroke, and endarterectomy has been proposed to prevent stroke during heart surgery in patients with arch atheromas.

Methods And Results: Intraoperative transesophageal echocardiography was performed in 3404 patients undergoing heart surgery between 1990 and 1996.

Cerebral injury after cardiac surgery: identification of a group at extraordinary risk. Multicenter Study of Perioperative Ischemia Research Group (McSPI) and the Ischemia Research Education Foundation (IREF) Investigators.

Background And Purpose: Cerebral injury after cardiac surgery is now recognized as a serious and costly healthcare problem mandating immediate attention. To effect solution, those subgroups of patients at greatest risk must be identified, thereby allowing efficient implementation of new clinical strategies. No such subgroup has been identified; however, patients undergoing intracardiac surgery are thought to be at high risk, but comprehensive data regarding specific risk, impact on cost, and discharge disposition are not available.

Guidelines for the treatment of acidaemia with THAM.

THAM (trometamol; tris-hydroxymethyl aminomethane) is a biologically inert amino alcohol of low toxicity, which buffers carbon dioxide and acids in vitro and in vivo. At 37 degrees C, the pK (the pH at which the weak conjugate acid or base in the solution is 50% ionised) of THAM is 7.8, making it a more effective buffer than bicarbonate in the physiological range of blood pH.

Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators.

Background: Acute changes in cerebral function after elective coronary bypass surgery is a difficult clinical problem. We carried out a multicenter study to determine the incidence and predictors of -- and the use of resources associated with -- perioperative adverse neurologic events, including cerebral injury.

Methods: In a prospective study, we evaluated 2108 patients from 24 U.

Multicenter preoperative stroke risk index for patients undergoing coronary artery bypass graft surgery. Multicenter Study of Perioperative Ischemia (McSPI) Research Group.

Background: The paradox of present cardiac surgery is that the more elderly and debilitated patients benefit most from cardiac surgery compared with medical therapy, yet they sustain greater overall risk for morbidity and mortality after cardiac surgery. The goal of the present study was to develop a preoperative index predicting major perioperative neurological events in patients undergoing coronary artery bypass graft surgery.

Methods And Results: As part of a prospective, multicenter, observational study (McSPI Research Group), we enrolled 2417 patients at 24 academic medical centers in the United States.

Effect of cannula length on aortic arch flow: protection of the atheromatous aortic arch.

Atheromatous disease in the transverse aortic arch is associated with an increased incidence of perioperative stroke. In addition, tissue erosion in the aortic arch is caused by the high-velocity jet emerging from an aortic cannula during cardiopulmonary bypass (CPB), termed the "sandblast effect". To quantify this phenomenon, flow in the aortic arch was measured intraoperatively by epiaortic ultrasonography in 18 patients undergoing CPB.

Superiority of transesophageal echocardiography in detecting aortic arch atheromatous disease: identification of patients at increased risk of stroke during cardiac surgery.

It has been shown that transesophageal echocardiography (TEE) is useful in evaluating atheromatous disease of the aortic arch and that such disease is a risk factor for stroke in medical patients. Data obtained by traditional methods of evaluating the aortic arch prior to cardiac surgery, namely, chest x-ray (CXR) and cardiac catheterization (CATH), were compared with that detected by TEE. Images of the descending thoracic aorta and aortic arch seen on intraoperative TEE in 258 cardiac surgical patients were graded as I = normal, II = intimal thickening or plaques < 5 mm thick or with a mobile component (severe disease).

Nimodipine decreases the minimum alveolar concentration of isoflurane in dogs.

Nimodipine is a calcium antagonist that binds with high affinity to neuronal membranes. It is a potent cerebrovasodilator and has been demonstrated also to affect neurotransmitter synthesis and release. Because patients undergoing surgery for intracranial aneurysms are frequently receiving nimodipine, the authors determined the MAC of isoflurane in six dogs before and during three infusion doses of nimodipine (0.

Effect of cardiopulmonary bypass on plasma levels of nifedipine.

Blood levels of many medications are acutely lowered by cardiopulmonary bypass (CPB). Because nifedipine is often used to provide protection from coronary ischemia, a determination of the effect of CPB on plasma nifedipine levels might help to determine the potential clinical benefit of nifedipine during and after bypass. Four samples of blood were drawn from each of eight patients undergoing cardiac surgery: one before, two during, and one after CPB.

Flumazenil decreases the minimum alveolar concentration isoflurane in dogs.

Flumazenil is a potent-specific benzodiazepine receptor antagonist that has been shown to reverse CNS depressant effects mediated by benzodiazepine agonists. These agonists are known to affect the interaction of gamma aminobutyric acid (GABA) with its receptor. Because the action of volatile anesthetic agents may be mediated by GABA, the authors determined the MAC of isoflurane in 16 dogs before and after one of three doses of intravenous flumazenil (0.

Uptake of arachidonic acid into membrane phospholipids: effect on chloride transport across cornea.

We demonstrate that arachidonic acid (AA) stimulation of chloride transport across frog cornea is mediated via two independent pathways: (1) stimulation of prostaglandins and cAMP synthesis, and (2) a direct physical change in the membrane produced by substitution of different phospholipid acyl chains. AA is well known as a precursor in the synthesis of prostaglandins, which have been shown to stimulate cAMP synthesis and chloride transport in frog cornea. We show that frog cornea can convert exogenous AA to PGE2, but that in the presence of 10(-5) M indomethacin both the conversion to PGE2 and stimulation of cAMP are completely blocked.