One month follow-up of haemostatic variables in patients undergoing aortocoronary bypass surgery. Effect of aprotinin.

It is already known that activation of the coagulation and fibrinolytic system occurs in patients undergoing cardiopulmonary bypass (CPB). We have thus studied twenty patients (10 treated with aprotinin during CPB and 10 untreated) both during the intraoperative period and during thirty days follow up. In untreated patients D-dimer levels increased 4-fold during CPB and the levels were above baseline for the whole follow up (p < 0.0001). D-dimer levels were reduced in aprotinin treated patients in comparison to untreated patients (p = 0.0172); levels then gradually increased to the values of the untreated patients over the following 24 h later and remained higher during the thirty day follow up. The behavior of haemostatic variables in the 24 h after CPB did not vary between untreated and aprotinin treated patients. In particular, five minutes after protamine sulphate administration, levels of F1 + 2 and TAT rose significantly (p = 0.0054, p = 0.0022 respectively), whereas fibrinogen significantly decreased (p < 0.0001) and PAI-1 antigen levels were reduced. Two days after CPB the concentrations of F1 + 2 and TAT lowered, whereas fibrinogen and PAI-1 antigen levels increased. On the 5th, 8th and 30th days after CPB, F1 + 2 and TAT levels remained higher than those reported at baseline in both groups of patients, whereas fibrinogen levels increased over basal levels in aprotinin treated patients only. Thus, in addition to the activation of the coagulation and fibrinolytic system occurring during the intraoperative period, in patients undergoing CPB, there are alterations of haemostatic variables up to thirty days from surgery.

Intravenous diltiazem in patients with paroxysmal re-entrant supraventricular tachycardia.

The electrophysiologic effects and efficacy of diltiazem were evaluated with programmed electrical stimulation of the heart in 12 patients with supraventricular re-entrant tachycardia (five with atrioventricular nodal tachycardia and seven with circus movement tachycardia the accessory pathway being concealed in 4). Diltiazem was infused over 1 minute at the dose of 0.25 mg/kg and the electrophysiologic parameters were evaluated at 5 and 30 minutes. Diltiazem prolonged the AH interval from 83.5 +/- 58 to 99 +/- 55 msec (P less than 0.05), effective and functional refractory periods of atrioventricular node from 244 +/- 40 to 268 +/- 56 msec (P less than 0.05) and from 432 +/- 124 to 468 +/- 130 msec (P less than 0.005) respectively, lowered the atrial pacing rate inducing second-degree atrioventricular block from 159 +/- 32 to 134 +/- 33 beats/min (P less than 0.005) and decreased systolic and diastolic blood pressure from 143.5 +/- 33 to 132.5 +/- 22 mm Hg (P less than 0.05) and from 90 +/- 15 to 82.5 +/- 9 (P less than 0.05), respectively. Diltiazem prevented the reinduction of the tachycardia in 4 of 5 patients with atrioventricular nodal tachycardia and in 4 of 7 with circus movement tachycardia. The mechanism of action of diltiazem consisted of depression of conduction in atrioventricular node in anterograde fashion while there were no effects on refractoriness of the accessory pathway. The drug was well tolerated with no adverse effects. Diltiazem, therefore, appears an effective and safe drug in the acute treatment of re-entrant supraventricular tachycardia.

Preoperative management and surgical therapy in complicated acute infective endocarditis: a 5-year experience.

Twenty-five patients underwent early and elective valve replacement for infective endocarditis during a 5-year period between April 1985 and March 1991. Indications for urgent surgical intervention performed at a mean 32 (range 6-47) days after admission were intractable heart failure, systemic emboli, septic multiorgan failure and the presence of vegetations. Indication for elective surgery was persistent (mean 42 (range 17-56) days) infection after appropriate antibiotic therapy. Twenty patients (80%) had a native valve endocarditis; five (20%) had prosthetic valve involvement. A total of 30 valvular prostheses were implanted: 22 (73.3%) were aortic (21 mechanical and one biological); eight (26.7%) were mitral (all mechanical). All unstable patients referred were treated before surgery in the intensive care unit and subjected to blood ultrafiltration to restore satisfactory circulatory parameters. No patient underwent cardiac catheterization; all patients were operated upon on the basis of echocardiographic data alone. One patient (4%) died during hospitalization; two (8%) died later at 48 and 12 months after the first intervention. The reoperation rate was 12%. After a mean follow-up of 49 (range 1-71) months, 21 of the survivors (95%) were in New York Heart Association functional class I or II; the actuarial 5-year survival rate was 87%. Precise preoperative assessment of early operative indications and timely association of medical therapy in unstable patients could represent a step forward in the treatment of acute infective endocarditis.