Hemodynamic effects of carbon dioxide insufflation during endoscopic vein harvesting.

BACKGROUND: A prospective study was performed assessing the hemodynamic effects of carbon dioxide (CO2) insufflation during endoscopic vein harvesting (EVH) using the Guidant Vasoview Uniport system. METHODS: Five hemodynamic and respiratory parameters (end-tidal carbon dioxide, arterial partial pressure of carbon dioxide, mean arterial pressure, mean pulmonary arterial pressure, and cardiac output), were measured in 100 consecutive patients undergoing EVH with CO2 insufflation. Data were obtained prior to commencement of EVH, 15 minutes after commencement, and 5 minutes after completion of the vein harvesting. RESULTS: No adverse hemodynamic effects were observed during CO2 insufflation. Specifically, average mean arterial pressure went from 88.77+/-9.64 to 89.13+/-8.60 to 88.24+/-8.71 mm Hg before, during, and after endoscopic vein harvesting (p = 0.291). Likewise, average mean pulmonary artery pressures were 19.76+/-4.75, 20.05+/-4.48, and 20.05+/-4.62 mm Hg (p = 0.547); and average cardiac output was 4.25+/-0.74, 4.22+/-0.73, and 4.23+/-0.69 L/min (p = 0.109) at those three intervals. Additionally, there was no evidence of significant systemic absorption of CO2 as reflected in average arterial PCO2, which remained steady at 37.42+/-5.19, 37.51+/-4.59, and 38.10+/-4.80 mm Hg (p = 0.217); and average end-tidal CO2, which was 32.10+/-3.66, 32.50+/-3.47, and 32.38+/-3.33 mm Hg (p = 0.335). In a subset of 20 patients with elevated pulmonary arterial pressure (more than 32 mm Hg), there was also no significant change in any of the parameters. CONCLUSIONS: Carbon dioxide insufflation during EVH leads to no adverse hemodynamic consequences or systemic CO2 absorption. The technique appears to be safe and well tolerated.

Mucormycosis of a median sternotomy wound.

Mucormycosis is an unusual complication of cardiothoracic surgery. The fungi may infect the sternotomy wound causing a progressive gangrene or seed the implanted prosthetic valve or graft resulting in endocarditis or graft failure. There have been six previous reports of mucormycosis following cardiothoracic surgical procedures. Four cases involved prosthetic devices, the remaining two are examples of sternal wound mucormycosis acquired from the use of contaminated elasticized bandages. The first case of sternal wound mucormycosis not associated with elasticized bandages is reported here. The infection occurred in a diabetic patient who had undergone coronary artery bypass surgery and mitral valve replacement. The patient received corticosteroids and broad-spectrum antibiotics at the time of and after operation. The patient developed invasive sternal mucormycosis and died on day 10 after surgery, despite aggressive surgical débridement and amphotericin B therapy. No elasticized bandages were used and the source of the infection was not identified. Previous cases of mucormycosis in cardiothoracic surgery are reviewed and the specific clinical setting in which this fungal disease should be suspected defined.

Lipomatous hypertrophy of the interatrial septum.

Lipomatous hypertrophy of the interatrial septum, a finding associated with obesity and advancing age, consists of accumulation of adipose tissue including fetal adipose tissue in the interatrial septum. It is a rare lesion of the heart and can reach notable size. A case is reported in which the diagnosis of lipomatous hypertrophy of the interatrial septum was established intraoperatively; the large bulk of the lipoma was such that it required major reconstruction of the interatrial septum and right and left atrial walls.

Aortoventriculoplasty in the management of an infected Cabrol graft.

This report describes use of a modified aortoventriculoplasty (Konno procedure) for reoperation on a patient with prosthetic aortic valve conduit endocarditis. The modified Konno procedure was necessary to expose the mid-left ventricular outflow tract to reconstruct an aortic annulus.

Mycotic aneurysm of the aortic arch with aortoesophageal fistula.

An elderly man presented with an aortoesophageal fistula (AEF) and underwent resection of a mycotic aneurysm of the aortic arch. After an initial success, the patient ultimately succumbed to mediastinal sepsis. The various approaches to combined aortic and esophageal pathology are presented with the recommendation for aortic replacement along with early removal of mediastinal contamination.

Repair of ventricular rupture following mitral valve replacement.

Left ventricular rupture is reported to occur in 0.5-2% of patients following mitral valve replacement and results in a high mortality rate. Three types of left ventricular rupture have been identified, each attributed to a different mechanism. Failure of repair has been due to repeated tearing of the ventricular muscle and resulting hemorrhage. We describe the repair of left ventricular rupture following mitral valve replacement with buttressed dacron patch. The repair is designed to eliminate the tension placed on the suture line. In addition, specific recommendations are made to avoid left ventricular rupture during mitral valve replacement.

Pulmonary edema following pericardiotomy for cardiac tamponade.

A 57-year-old man with a history of a previous myocardial infarction presented with acute cardiac tamponade due to malignant pericardial effusion. Immediately following emergency surgical drainage of the pericardium by subxiphoid window, acute pulmonary edema developed. The sudden increase in venous return following the release of cardiac compression may result in this rare complication. Gradual removal of pericardial fluid under hemodynamic monitoring is advisable, particularly in patients with preexisting heart disease.