Successful coronary artery bypass surgery in a patient with AIDS.

We report the case of a 47-year-old man with AIDS who underwent a successful quadruple coronary artery bypass operation. The improving prognosis of patients with HIV/AIDS, in addition to the reported incidence of plasma lipid abnormalities in patients receiving protease inhibitors, are laying the groundwork for a larger population in which premature coronary artery disease develops. Operative risk, immunosuppressive effect of cardiopulmonary bypass, and practical considerations in the care of these patients are discussed.

Left ventricular fibroma masquerading as postinfarction myocardial rupture.

A large left ventricular fibroma was encountered perioperatively for what was presumed to be a sealed ventricular rupture after thrombolytic therapy for an acute myocardial infarction. We review the pertinent literature concerning the diagnosis of ventricular rupture and this rare benign tumor of the heart.

Coronary artery bypass grafting in immune thrombocytopenic purpura.

BACKGROUND: Reports of patients with idiopathic thrombocytopenic purpura undergoing cardiac operations are scarce and no recommendations exist regarding their management. We report 3 patients with idiopathic thrombocytopenic purpura and severe coronary artery disease who underwent uncomplicated coronary bypass grafting. METHODS: The case history of each patient with idiopathic thrombocytopenic purpura who underwent coronary artery bypass grafting and the literature were reviewed. RESULTS: All 3 patients underwent uncomplicated coronary artery bypass grafting after preoperative treatment with intravenous immunoglobulin and intraoperative platelet transfusions if needed. Prophylactic splenectomy was not performed. There was no increased incidence of bleeding complications. CONCLUSIONS: Coronary artery bypass grafting can be safely performed in patients with idiopathic thrombocytopenic purpura using conventional conduits after pretreating with immunoglobulin G and avoiding splenectomy.

Aortic stenosis in the elderly: result of aortic valve replacement.

Forty-six patients, 24 male and 22 females, with a mean age of 78.4 years (range 75 to 88) underwent aortic valve replacement (AVR) for severe calcific aortic stenosis during a five year period. Twenty-six patients (56.5%) had combined aortic valve replacement/coronary artery bypass (AVR/CABG) procedures. Bovine pericardial or porcine bioprostheses were used in 47.8% of cases. The mean length of stay in the intensive care unit was 2.9 days (range 2-13) with a mean hospital stay of 12.6 days (range 6-41). Operative mortality rate was 6.5% (3 patients), all in the AVR/CABG group. Complications included pneumonia (8.7%), stroke (6.5%), and complete heart block requiring pacemaker insertion (6.5%). Follow-up of survivors from 11-69 months (mean 34.6) shows 92.9% survival, with 87.2% in New York Heart Association (NYHA) Class I and II. Aortic valve replacement in the elderly population has an acceptable mortality rate and is associated with significantly improved quality of life over the intermediate term.

Reduction of bleeding after heart operations through the prophylactic use of epsilon-aminocaproic acid.

UNLABELLED: Excessive postoperative bleeding after heart operations continues to be a source of morbidity. This prospective double-blind study evaluated epsilon-aminocaproic acid as an agent to reduce postoperative bleeding and investigated its mode of action. One hundred three patients were randomly assigned to receive either 30 gm epsilon-aminocaproic acid (51 patients) or an equivalent volume of placebo (52 patients). In a subset of these patients (14 epsilon-aminocaproic acid, 12 placebo), tests of platelet function and fibrinolysis were performed. RESULTS: By multivariate analysis, three factors were associated with decreased blood loss in the first 24 hours after operation: epsilon-aminocaproic acid versus placebo (647 ml versus 839 ml, p = 0.004), surgeon 1 versus all other surgeons (582 ml versus 978 ml, p = 0.002), and no intraaortic balloon versus intraaortic balloon pump use (664 ml versus 1410 ml, p = 0.02). No significant differences in platelet function could be demonstrated between the two groups. Inhibited fibrinolysis, as reflected by less depression of the euglobulin clot lysis and no rise in D-dimer levels, was significant in the epsilon-aminocaproic acid group compared with the placebo group. CONCLUSION: The intraoperative use of epsilon-aminocaproic acid reduces postoperative cardiac surgical bleeding.

Successful management of intracardiac extension of tumor thrombus in a patient with advanced nonseminomatous germ cell testicular cancer.

A young patient with testicular germ cell tumor presenting with inferior vena cava thrombus extending into the right heart with free-floating thrombus in the right ventricle and a simultaneous epidural spinal cord compression is presented. Due to the perceived high risk of embolization and the urgent need to begin systemic chemotherapy, he was managed with tumor thrombectomy utilizing cardiopulmonary bypass and hypothermic circulatory arrest followed shortly thereafter by systemic chemotherapy. There were no perioperative complications, and he is alive and without recurrence 24 months following four cycles of systemic chemotherapy.

Aneurysm following ligation of patent ductus arteriosus.

Complications following ligation of patent ductus arteriosus are rare. Aneurysm following ligation requires careful evaluation and individualized repair. We report 2 cases that highlight the clinical course and operative management of this unusual but significant postoperative complication.