Closed commissurotomy versus balloon valvuloplasty for rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: Closed mitral commissurotomy (CMC) and percutaneous mitral balloon valvuloplasty (PMBV) were compared by their initial results and Doppler echocardiographic data obtained at one week and one year after the procedure. METHODS: Of 580 patients with severe rheumatic mitral stenosis, 280 underwent CMC and 300 PMBV. The mean pre-procedural transmitral gradient (TMG) was 21 +/- 6 mmHg in the CMC group and 20 +/- 5 mmHg in the PMBV group (p = 0.6); the mean mitral valve area (MVA) was 1.1 +/- 0.2 cm2 in both groups. RESULTS: Mortality was 0.7% after CMC and 0.3% after PMBV; the primary success rates were 98.3% and 89% respectively (p <0.0001). Two CMC patients and three PMBV patients underwent emergency mitral valve replacement. At the first week, the mean TMG was decreased to 4 +/- 3 mmHg in the CMC group, and to 5.8 +/- 2 mmHg in the PMBV group (p <0.0001). The mean MVA was increased to 2.5 +/- 0.5 cm2 after CMC, and to 2.1 +/- 0.4 cm2 after PMBV (p <0.0001). After one year, TMG was 5.4 +/- 4 mmHg in the CMC group (p <0.0001) and 7.1 +/- 3 mmHg in the PMBV group (p <0.0001); MVA was 2.3 +/- 0.5 cm2 (p <0.0001) and 1.9 +/- 0.4 cm2 (p <0.0001), respectively. The results of CMC were significantly better (p <0.0001) with regard to TMG and MVA at these times. A significant decrease was also seen in mean left atrial diameter and pulmonary artery pressure in both groups (p <0.0001). CONCLUSION: Although satisfactory results can be achieved using either approach, CMC provides a higher primary success rate, greater MVA augmentation, and better technical control during the procedure, while reducing the cost. PMBV shortens in-hospital stay and eliminates the risk imposed by thoracotomy and anesthesia. Therefore, in our practice, when surgical intervention is contraindicated due to associated problems, PMBV may be the preferred approach, but exposure to radiation may be of concern in pregnant patients.

An alternative application of sodium nitroprusside to overcome perioperative spasm of the internal thoracic artery.

OBJECTIVE: The internal thoracic artery (ITA) is currently the preferred conduit for myocardial revascularization; however, perioperative vasospasm of the internal thoracic artery may cause morbidity. Pedicle preparation and pharmacological vasodilatory treatment vary greatly. This clinical study was performed in order to define the effectiveness of two different applications of sodium nitroprusside as vasodilating agent. METHODS: Eighty-six (86) consecutive patients whose left internal thoracic artery was mobilized only by one surgeon for elective coronary artery bypass graft operations were randomly divided into two groups. The internal thoracic artery was allowed to bleed freely, and the flow was determined (flow 1). In group I (n=42) 3mg sodium nitroprusside in 10ml of 5% dextrose solution was sprayed with pressure on the pedicle with a thin 25 gauge needle. In group II (n=44) half of the solution was sprayed in the same manner, and the other half of the solution was injected into the pedicle in the periarterial tissue along the length of the pedicle. Free flows of the internal thoracic artery were registered before cardiopulmonary bypass (flow 2) and also just prior to performing internal thoracic artery anastomosis to the left anterior descending artery (flow 3). With each measurement hemodynamic parameters and the time between measurements were recorded. RESULTS: No statistically significant differences were found between the groups in respect to sex ratio, age, body surface area, heart rate 1 and 2, mean arterial pressure 1 and 3. There was no significant difference in the initial flow among groups. Significant differences were noted in the second flow measurement (P<0.05) and in the third flow measurement (P<0.01) between two groups. For each group there was a significant increase in flow from flow 1 to flow 2 and from flow 2 to flow 3 (P<0.02). CONCLUSION: Sodium nitroprusside injection to the pedicle provides a better flow than simple spraying of the same agent.

Sequential revascularization of intramuscular left anterior descending coronary artery.

We present a new technique for avoiding possible kinking or angulation of the sequential left internal mammary artery to left anterior descending artery (LIMA-LAD) anastomoses when the LAD follows an intramuscular course. A 3- to 5-mm cusp of saphenous vein segment is interposed between the intramuscular LAD segment and internal mammary artery (IMA) at the sequential anastomotic site, to which the distal portion of the IMA was anastomosed in standard end-to-side fashion.

Hemodynamic effects of acute intestinal ischemia.

Twelve animals entered in this study with the aim of documenting that superior mesenteric artery small occlusions lasting for one hour have adverse effects on the myocardium. Three hours after cross clamp removal CO decreased to 1.07 +/- 0.11 from 1.99-0.09 a preoperative value (p < 0.01) and PCWP increased to 17 +/- 3 from 8 +/- 3 a preoperative value. MOE reduced to 40-5% 3 hours after cross clamp removal. MLE was -0.21 +/- 0.11 three hours after clamp removal. Changes in MOE and MLE were commented as a defect in myocardial aerobic metabolism. As a result of this study it was concluded that toxic mediators are released from the intestine being reperfused after temporary occlusions of the SMA impair myocardial metabolism, resulting in decreased hemodynamic functions.

Routine coronary arteriography before abdominal aortic aneurysm repair.

BACKGROUND: As cardiac complications constitute the principal cause of early and late morbidity and mortality after the surgical treatment of abdominal aortic aneurysm (AAA), a prospective study was planned to evaluate the effects of revascularization of coronary arteries on survival after AAA repair during early and long-term follow-up periods. PATIENTS AND METHODS: A total of 125 patients underwent elective repair of AAA between 1986 and 1994. Coronary arteriography was performed in all cases. All cases with critical left anterior descending artery (LAD) lesions underwent a coronary artery bypass operation either simultaneously or shortly before AAA repair. In addition, percutaneous transluminal coronary angioplasty (PTCA) was performed for symptomatic and critical stenosis of arteries other than the LADs, or if noncritical but symptomatic stenosis of the LADs existed. Early and late follow-up data were obtained for all cases, and late-term cumulative survival rates were calculated. RESULTS: Coronary artery lesions were found in 66 (53%) cases. In 24 cases, AAA repairs were performed 2.3 (mean) months after coronary artery bypass grafting (CABG), whereas in 4 cases both procedures were performed simultaneously. PTCA was performed in 4 cases 3 to 4 days prior to the abdominal surgery. Even though the coronary artery lesions were found inoperable in 7 cases, these patients underwent repair of AAA because of rapidly expanding and painful aneurysms. Early mortality rate was 4% (5 cases), in which 3 of these were from the group inoperable for CABG. A mean follow-up of 3.17 years (3 to 87 months) was achieved for all discharged patients. Cumulative survival rates for 6 months and 1, 2, 3, and 6 years were 99%, 99%, 95%, 93%, and 89%, respectively. CONCLUSIONS: The results of this study emphasize the importance of coronary artery revascularization for early, and especially for late, survival after AAA repair.