BACKGROUND:Intraoperative blood loss and postoperative anemia have been a concern when more than 1500 ml of lipoplasty material is aspirated. Blood loss is minimal when the targeted area is infiltrated with large volumes of dilute lidocaine and epinephrine. However, little quantitative data are available regarding the intraoperative blood loss and postoperative hemoglobin drop.METHODS:In this prospective study 38 consecutive women were investigated with preoperative measurement of hemoglobin, platelet count, prothrombin time, activated partial thromboplastin time, and postoperative measurement of hemoglobin. Hemoglobin and whole blood volume were calculated from the infranatant portion of the lipoplasty aspirate. All procedures were done with the patient under general anesthesia.RESULTS:The mean (+/-SD) volume of lipoplasty aspirate material was 2900+/-14702.8 ml (range 1000 to 5800 ml). The mean (+/-SD) whole blood volume in lipoplasty aspirate per case was 36+/-50.82 ml (range 1.2 to 251 ml). The mean (+/-SD) fall in hemoglobin was 0.93+/-0.92 gm/dl (range 0.2 to 4.3 gm/dl). The volume of whole blood loss was estimated to be 12.4 ml in each 1000 ml of lipoplasty aspirate. No blood transfusions were required.CONCLUSION:Data show that blood loss with the tumescent technique is remarkably low. Use of this technique permits large-volume lipoplasty aspirate and minimizes the need for blood transfusion.

The focus of new research efforts to improve the morbidity and mortality associated with acute myocardial infarction (AMI) has turned to adjuvant agents that show promise of improving outcomes following coronary thrombolysis. We enrolled 162 patients with AMI in a randomized trial comparing front-loaded tissue-plasminogen activator (t-PA) plus weight-adjusted heparin with anisoylated plasminogen streptokinase activator complex (APSAC) without heparin as well as standard-dose (325 mg) and low-dose (81 mg) aspirin. The primary end point was an in-hospital morbidity profile; secondary end points were clinical and angiographic potency and hemorrhagic events. Selected sites performed an electrocardiographic substudy to determine the time to 50% ST-segment recovery and the time to steady state. Although the trial was terminated when the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries-I trial showed that t-PA had a significant mortality advantage over streptokinase, important trends were evident. Patients given t-PA and heparin were better anticoagulated (p = 0.001), yet AP-SAC-treated patients had more bleeding complications. The primary end point favored t-PA (25.4% vs 31.3%), and the secondary end points were similar in both groups. In the electrocardiographic substudy, the t-PA group achieved both 50% ST-segment recovery and steady-state recovery sooner than the APSAC group. Patients taking low-dose aspirin had lower in-hospital mortality and less recurrent ischemia but more strokes than the standard-dose aspirin group. Thus, this trial demonstrated trends favoring front-loaded t-PA with weight-adjusted heparin over APSAC without heparin in the treatment of AMI. The use of low-dose aspirin did not appear to impose a loss of protection from adverse events, nor did standard-dose aspirin increase serious bleeding.

The long-term prognosis of exercise-induced left bundle branch block (BBB) in patients with and without underlying coronary artery disease (GAD) was examined by following 15 patients (7 with normal coronary arteries and 8 with CAD) for an average of 6.6 years (range 2.2 to 11.2). Over the follow-up interval, permanent left BBB developed in 8 of the 1.5 patients. Seven of these 8 had underlying CAD, compared to 0 of 6 patients with normal coronary arteries and normal left ventricular function (p < 0.002). In 1 patient with normal coronary arteries and a left ventricular ejection fraction of 0.34, permanent left BBB developed. During follow-up, 4 patients died; 3 had significant CAD and 1 had depressed left Ventricular function. In no patient did high-grade atrioventricular block develop and no patient required pacing. Thus, development of permanent left BBB in patients with exercise-induced left BBB is related to presence or absence of underlying CAD or myocardial disease. When left BBB is found in the absence of underlying heart disease, there does not tend to be progression of the conduction disturbance and the prognosis is excellent.

A clinical observation of chest pain associated with the onset of rate-related left bundle branch block has been described in patients with normal coronary arteriograms. The authors used standard cardiac rehabilitation techniques for exercise training in a 47- year-old woman with these manifestations. Serial treadmill tests revealed that during the course of 3 months of exercise training, the heart rate at onset of LBBB gradually rose from 133 to 175 beats per minute, and she no longer developed symptoms during her routine daily activities or exercises. Exercise training was a successful nonpharmacologic strategy that delayed the onset of rate-related LBBB and chest pain in this patient and avoided the need for beta blocker therapy.