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From the introduction: What follows in the next pages is a tabulation of results of open heart surgery in 1880 patients who were admitted to the cardiovascular surgery unit during the period May, 1956-May, 1969. Surgical mortality and morbidity data are presented in a brief manner. I have tried to interpret the results in light of the similar experience of others. This digestion of the work of others with enzymes of one's personal experience is not always palatable, especially when the latter is admittedly limited.

[Truncated abstract] Cardiac surgery involving cardiopulmonary bypass is a complex procedure that results in significant changes to blood coagulation, fibrinolytic biochemistry, platelet number and function, and the vasculature. These are due to pharmacological agents which are administered, haemodilution and contact of the blood with artificial surfaces. Consequently there are significant risks of thrombosis and haemorrhage associated with this procedure. The research presented in this thesis utilises in vitro, in vivo, and a novel ex vivo model to investigate the nature of the haemostatic defect induced by cardiopulmonary bypass. The components studied include the drugs heparin, protamine sulphate, and aprotinin, different types of bypass circuitry (including heparin bonded circuits) and procedures such as acute normovolaemic haemodilution. Patient variables, such as Factor V Leiden, are also studied. Each of these components is assessed for the effects on a number of laboratory measures of haemostasis including activated partial thromboplastin time, prothrombin time, activated protein C ratio, antithrombin concentration, heparin concentration, thrombin-antithrombin complex formation, prothrombin fragment 1+2 formation, markers of platelet surface activation and secretion, activated clotting time, haemoglobin concentration and coagulation factor assays.

Coronary bypass surgery is an increasingly common occurrence. Current literature does not validate the coping mechanisms involved for patients facing this life-threatening event. Lazarus’ theory of stress and coping was utilized as the framework for the study. The purpose of the study was to identify the degree of threat coronary bypass surgery presents and coping mechanisms utilized with this specific insult. The significance of the study was to assist nurses in identification of perceived risks/benefits of having open heart surgery from the patient’s perspective. The population included patients from a private cardiovascular practice in Indianapolis, Indiana. The convenience sample included 38 subjects recovering from coronary bypass graft surgery. Subjects were identified as uncomplicated post-operative surgical patients and were mailed questionnaires one month after discharge from the hospital. The Jalowiec Coping Scale and a questionnaire for demographic data were utilized to collect data. Procedures for protection of human subjects were followed. The research design was non-experimental and descriptive, correlational procedures were utilized to analyze data.The data supported the notions that clients utilized both problem-focused coping and emotion-focused coping, and emotion-focused coping strategies were more effective in reducing the threat. Education was significantly related to emotive coping styles and clients that perceived a higher threat intensity utilized more emotion-focused coping strategies. Recognition of the need to minimize stressors can be an important role the nurse facilitates. Through participatory care, the nurse may assist in finding the meaning for the stressor and encourage open communication patterns and emotional responses. Allowing for reduction of threat perception and intensity may enhance the outcome of the experience. / School of Nursing

The experience of living through an unexpected, life-threatening cardiovascular surgery can be a profound. This study examined the experience of 4 men who had survived ruptured aortic aneurysm using a phenomenological research design.Audio-taped interviews were analyzed for common themes and patterns. Two strong, opposing constitutive patterns were found. The patterns the data conveyed were: 1) fear as a response to overwhelming pain and clouded perceptions, and 2) gratitude for recovery in an atmosphere of caring support.This study was significant in beginning to bring to understanding the phenomenon of surviving major, unexpected cardiovascular surgical trauma. It is recommended that health care providers be more attentive to similar patients' experiences and listen to how their lives have changed as a result of their experiences. / School of Nursing

Heart disease remains the most important non-obstetric cause of maternal mortality and morbidity during pregnancy, despite its low incidence of less than 1%. This is due to the decline in the number of deaths from haemorrhage, infection and toxemia. In addition, a striking change in the pattern of proportional distribution of organic heart disease in pregnant women is being noted, with a decrease in chronic rheumatic lesions and an increase in congenital cardiac disease. In the Third World rheumatic mitral valve disease remains a most important condition during pregnancy. It is currently rarely seen in Europe and the United States. Mitral stenosis is the most commonly encountered rheumatic heart lesion that complicates pregnancy. The normal circulatory changes during pregnancy aggravate this lesion as the reduced, fixed valve area obstructs blood flow from the left atrium to the left ventricle, causing pulmonary congestion and oedema. Careful and regular follow up of these patients is essential, and surgery is indicated if optimal medical management fails. Cardiac surgery duting pregnancy represents a risk to both the foetus and the mother. For most procedures extracorporeal circulation and heparinization are necessary and adds to the · adverse effects of the operation. Closed mitral valvotomy, however, is an excellent low risk operative procedure in patients with tight mitral stenosis without causing undue harm to the foetus. Cuttler described the first attempted surgery of the mitral valve in 1923 and since then the procedure has been improved to benefit many patients with tight mitral stenosis. The first reports of closed mitral valvotomy during pregnancy were in 1952. Al though a more precise valvotomy can be obtained with an open procedure, the closed operation avoids the risks of extracorporeal circulation, particularly detrimental to the foetus. This report is a review of the Groote Schuur Hospital experience of patients with mitral stenosis requiring closed mitral valvotomy during pregnancy since 1965. The aims of the study are to analyse the outcome of the pregnancy, the effects of valvotomy during pregnancy on both the mother and the foetus, and the outcome regarding restenosis of the mitral valve.

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Submitted in partial fulfilment of the requirements for the Degree of Masters in Technology: Clinical Technology, Durban University of Technology, 2009. / Currently, off-pump coronary artery bypass surgery (OPCAB) is a selectively employed technique for myocardial revascularization used in the majority of heart units worldwide. This strategy obviates the documented deleterious effects of cardiopulmonary bypass. However the occurrence of neurological sequelae associated with OPCAB ranges from minor cognitive dysfunction to major stroke. Haemodynamic instability throughout the positioning, stabilization and interruption of coronary blood flow are regarded as important factors that affect the performance of off-pump surgery. Fluctuations during the perioperative period, in particular manipulation of the heart could result in temporary brain hypoperfusion and neurological sequelae. To predict those patients that are predisposed to cerebral complications, investigators have used neurological monitoring, in particular Near-infra red spectroscopy (NIRS) during cardiac surgery. Aims and Objectives of the study This prospective, observational study was carried out to assess the correlation between cerebral oxygen saturation and central venous saturation during OPCAB surgery. Central venous saturation is an important variable used to assess global tissue perfusion and could therefore be advocated as a surrogate measure of cerebral oxygen saturation. In addition variables such as mean arterial (MAP) pressure, heart rate (HR), patient oxygen saturation (SpO2), partial pressure of carbon dioxide (PcvCO2), haematocrit (Hct) and lactate were also measured to determine if they were independent predictors of cerebral desaturation. This study is one of the first done in the South African population group. iv Methodology Twenty patients undergoing OPCAB surgery from the Cardiothoracic unit at Inkosi Albert Luthuli Central Hospital, Durban, South Africa were recruited in the trial. Cerebral somasensors were placed on the patients forehead to measure left and right cerebral saturations. These sensors were linked by cables to the cerebral monitor (NIRS), INVOS model 5100C. Eight time periods throughout the surgical procedure whereby patients would be haemodynamically unstable were identified. These time periods included, post induction and pre sternotomy, pre and post placement of swabs beneath the heart, pre and post placement of the stabilizer device (Octopus), pre and post snaring of the LAD (left anterior branch of the coronary arteries), pre anastomosis and during anastomosis of the coronary arteries, second sample during anastomosis and post anastomosis, pre and post removal of swabs from beneath the heart, pre and post transfer of the patient to the ICU bed. These time periods constituted the sampling period pre and post manoeuvres. Eight paired measurements, i.e., MAP, PaCO2, HR, Hct, lactate, SpO2, central venous saturation (ScvO2) and cerebral oxygen saturation (rSo2) per patient were taken during these time periods. Recording of cerebral saturations and blood samples from the central venous line were taken during these eight time periods in order to determine the correlation between central venous and cerebral oxygen saturations. Results Strong positive correlations between central venous saturation and cerebral saturation presented in majority of the sampling time periods throughout the study (post induction and pre sternotomy, post placement of swabs beneath the heart, post snaring of the LAD (left anterior branch of the coronary arteries, pre anastomosis and during anastomosis of the coronary arteries, second sample during v anastomosis, pre and post transfer of the patient to the ICU bed). The positive correlation indicates that central venous saturation can be used as a surrogate measure of cerebral oxygen saturation during OPCAB surgery. Conclusion The absence or poor correlation of MAP, HR, PcvCO2, heamatocrit, lactate, and patient saturation to cerebral saturation in this study suggests that insertion of a central venous line (CVP) during OPCAB should be a fundamental clinical requirement.

The purposes of this research were to: (1) describe selected fluid and electrolyte changes that occur during the first four hours after open heart surgery; (2) determine whether significant hourly changes occurred in: blood pH, fluid intake, exogenous potassum chloride replacement, fluid output, or serum and urinary sodium and potassium levels; and finally, (3) delineate which of the above variables were most strongly related to changes in serum and urinary, sodium and potassium levels. Fifty-three patients who had undergone cardiac surgery involving cardiopulmonary bypass were studied. Urine and blood samples were collected every hour for the first four hours postoperatively and were analyzed for sodium and potassium content using flame photometry. Blood pH and exogenous potassium chloride replacement were recorded from the anesthesiologist's and nurse's records. Fluid intake and fluid output were measured directly by the investigator. Analyses included both descriptive and correlational statistics. In addition, a repeated measures procedure (MANOVA) was performed to discern performance trends over time. The data showed that hypokalemia (defined as a serum potassium level less than 4.0 mEq/L) was present in approximately 52 percent of the subjects for the first two postoperative hours and that by the fourth hour only 15 percent of the subjects were hypokalemic. In addition, subjects were noted to retain 2.47 liters of fluid over the four hour period. Significant differences in fluid output were noted across time. Serum sodium levels did not change significantly across time even though serum potassium levels did. The data indicated that the best predictors of hypokalemia were fluid intake and fluid output. Both of these variables had a significance level of p = .000. Regression analysis showed that fluid intake and exogenous potassium chloride replacement explained 11.9 percent of the variance in serum potassium at a significance level of p = .008. Furthermore, fluid output explained 7.3 percent of the variance in urinary potassium (p = .030).

Traveling teams of cardiovascular specialists visit poor countries to treat children born with life-threatening heart defects. Working within challenging settings, volunteers may need to build temporary operating theaters and neonatal intensive care units before beginning their work. They also try to extend their humanitarian reach beyond the confines of an in-country visit: they train locally-based personnel in surgical and critical care techniques considered routine in rich countries yet locally unavailable; they donate machines, hardware, and disposable materials to local hospitals; they even build permanent surgical centers. Pediatric heart surgery missions thus define a new context where medical technologies circulate globally. It is well-known that medical technologies have far-reaching effects, transforming societies while at the same time being transformed by them, but few scholars have explored these processes in medical humanitarian arenas. This study investigates the moral logic, medical logistics, and unanticipated effects of short-term surgical missions. The setting is Honduras: a known hub of medical mission activity. The study begins with an examination of why Honduras attracts scores of medical missions, and why children with heart defects have emerged as central objects of humanitarian concern. I argue that humanitarian sentiments dovetail with other interests and desires on the part of surgical volunteers, such as adventure travel, learning, and the allure of practicing an alternative, low-tech version of biomedicine as a corrective to disappointments, frustrations, and lulls in their everyday professional lives. I then describe how this humanitarian ethos reconfigures biomedical practice. This is followed by a discussion of the implications of pediatric heart surgery missions for host countries, such as how they inadvertently re-inscribe social hierarchies and place strain on existing health services. Finally, I follow the lives of pediatric heart patients after their surgeries, show how their parents contest any stereotypical assumptions about humanitarian aid beneficiaries, and unpack the logic underpinning consent for especially high-risk procedures. My analysis emerges from 13 months of ethnographic field research primarily in Tegucigalpa, the nation’s capital, during which I participated in six pediatric heart surgery missions, and observed and interviewed volunteer clinicians, locally-based clinicians, and the parents of pediatric heart surgery patients.