Selection and care of cardiac patients for plastic surgery

A major operation after successful coronary artery bypass surgery has been proved as safe as an operation for a patient free from coronary artery disease. Most patients with angina who demonstrate an operable coronary lesion should usually be scheduled for coronary artery bypass before undergoing nonemergency surgery. It is advisable to postpone elective plastic surgery for 6 weeks to 3 months after coronary bypass and 6 months after myocardial infarction. The life expectancy of cardiac patients must be carefully considered before elective plastic surgery, because performing an operation on a patient who cannot live to enjoy the benefits is unwise. Working together, cardiac surgeons, cardiologists, and plastic surgeons can now prolong the quantity of life and enrich its quality in properly selected and carefully managed patients.     

TOTAL PHYSIOLOGIC CORRECTION OF TRICUSPID ATRESIA WITH ATRIAL SEPTAL DEFECT-VENTRICULAR SEPTAL DEFECT CLOSURE AND A RIGHT ATRIUM-RIGHT VENTRICLE NON-VALVED CONDUIT: CASE REPORT

An 18-year-old woman underwent total physiologic correction of tricuspid atresia (atrial septal defect-ventricular septal defect closure and a right atrium-right ventricle non-valved conduit). Postoperative studies documented excellent hemodynamic results. The patient remains asymptomatic 6 months after surgery.     

CARDIOGENIC ACUTE RENAL FAILURE (CARF) FOLLOWING OPEN-HEART SURGERY

Although previous reports have attributed acute renal failure (ARF) following cardiovascular surgery to acute tubular necrosis (ATN), little emphasis has been placed on renal failure due to congestive heart failure (CARF). Of 100 cases of ARF studied prospectively over an 18-month period, 36 occurred after open-heart surgery. Nineteen of these cases were associated with heart failure. The remaining 17 had ATN as manifested by high urinary sodium, low urine/plasma creatinine, and abnormal urinary sediment. At the onset of CARF, intravascular volume expansion was universally present, and oliguria with pulmonary edema was common. Urinary chemistries were (mean +/- SD): sodium (mEq/L) 8 +/- 7, U/P creatinine 72 +/- 45, and FENa (%) 0.1 +/- 0.1. Therapy consisted of digoxin, furosemide (F), vasopressors (V), and, when indicated, intraaortic balloon counterpulsation. Survivors of CARF responded more frequently to F and required less V. Ultimately, survival depended upon improvement in cardiac performance. All oliguric ATN patients failed to respond to F. Mortality for the CARF group was 52%. In contrast, 82% of the oliguric ATN group expired, whereas overall ATN mortality was 60%. Cardiogenic acute renal failure is a frequent cause of ARF after open-heart surgery in our institution. It is characterized by prerenal urinary chemistries, has a high mortality, and may be reversible.     

COMBINED REPLACEMENT OF THE AORTIC VALVE AND ASCENDING AORTA IN JEHOVAH'S WITNESSES: REPORT OF TWO CASES

Two Jehovah's Witnesses with large ascending thoracic aortic aneurysms and aortic insufficiency secondary to annuloaortic ectasia underwent successful combined replacement of the aortic valve and the ascending aorta. One patient received a composite graft containing an aortic valve prosthesis, which necessitated supravalvular coronary ostia reimplantation; the other patient underwent separate aortic valve and left supracoronary ascending aneurysm replacement, with reimplantation of the right coronary ostium into the graft. No blood or blood derivatives were administered. Both patients had uneventful recoveries and continue to do well. To our knowledge, they represent the first reported cases of successful combined replacement of the aortic valve and ascending aorta in Jehovah's Witnesses.     

Active Management of Labour

Active management of labour has been developed to the extent that an assurance is given to every woman who attends this hospital that her first baby will be born within 12 hours. This assurance could lead to a welcome change in present attitudes because the mere prospect of prolonged labour is often a cause of serious concern during a first pregnancy. Labour of strictly limited duration makes it possible to provide every woman with a personal nurse, and it places the problem of pain in a new setting.The results of a prospective study of 1,000 consecutive primigravidae are presented, and the guidelines to a standard policy of management are defined. Difficulty in meeting the commitment to early delivery arose almost exclusively in cases in which the diagnosis of labour was in doubt; only seven women were retained in the delivery unit for 12 hours.