Aortocoronary vein graft surgery in a cadaver kidney transplant recipient.

A case of Prinzmetal angina occurred in a recipient of a cadaver kidney transplant who was treated with aortocoronary vein graft. The patient had severe retrosternal chest pain associated with ST-segment elevation in the precordial leads. Coronary arteriograms disclosed two major lesions in the proximal anterior descending artery. Aortocoronary vein graft was successfully performed with no untoward effect on the renal status. The patient has been free of angina approximately two years postoperatively.

Use of a ringed intraluminal graft in the surgical treatment of dissecting aneurysms of the thoracic aorta. A new technique.

An intraluminal graft made of woven tubular Dacron with cloth-covered grooved rings at both ends is used to repair dissecting aneurysms of the thoracic aorta. Six consecutive white male patients ranging in age from 31 to 69 years with an average age of 55 years were operated upon with the use of this graft. Three patients had a dissecting aneurysm of the ascending aorta and three others had a dissecting aneurysm of the descending aorta. Total cardiopulmonary bypass was utilized in repairing dissecting aneurysms of the ascending aorta and left heart bypass was used in patients with dissecting aneurymsms of the descending aorta. The basic technique consists in inserting the whole ringed graft into the true lumen of the dissected aorta and circumferentially ligating the aorta against the groove in the rings. The proximal ring of the graft effectively stabilized the flail aortic valve in two patients with aortic regurgitation associated with dissection of the ascending aorta. There were no hospital deaths. All patients are doing well 1 year, 1 month to 2 years, 8 months after the operation.

Spontaneous disruption of Ionescu-Shiley bovine pericardial xenograft in the mitral position.

We report a case of spontaneous disruption of the Ionescu-Shiley pericardial xenograft in the mitral position at 3 years and its successful management.

Isolated rupture of the right ventricle in a patient with acute inferior wall MI.

A case of isolated rupture of the right ventricle secondary to acute MI, presented as cardiac tamponade, is reported. The patient underwent successful emergency surgery for closure of the right ventricular rupture without aortocoronary bypass.

The effect of desmopressin acetate on postoperative hemorrhage in patients receiving aspirin therapy before coronary artery bypass operations.

It has been suggested that desmopressin acetate has been effective in reducing hemorrhage after coronary artery bypass grafting in patients receiving aspirin before operation. We conducted a prospective, randomized, placebo-controlled, double-blind trial to determine the effectiveness and safety of desmopressin in these patients. Sixty-five patients pretreated with aspirin within 7 days before their scheduled elective coronary artery bypass grafting were randomized to receive desmopressin (0.3 micrograms/kg) or placebo after cessation of bypass and reversal of heparin with protamine. The demographic characteristics and last dose of aspirin were similar in both groups. There was a significant reduction in postoperative blood loss noted between groups for both chest tube blood loss (833 +/- 311 ml for the 1-desamino-8-D-arginine vasopressin [desmopressin] group versus 1176 +/- 674 ml for the placebo group; p = 0.016) and total blood loss (1215 +/- 381 ml for the desmopressin group versus 1637 +/- 761 ml for the placebo group; p = 0.0097). Despite the differences in blood loss between the two groups, the red cell transfusions were not significantly different, but the use of platelets was less in the desmopressin group and almost achieved statistical significance (p = 0.053). Neither was there a difference in the occurrence of thrombotic complications between groups. It appears that desmopressin in this specific subgroup of patients receiving preoperative aspirin is effective as a prophylactic agent for reduction of postsurgical hemorrhage.

The behavior of antithrombin III, alpha 2 macroglobulin, and alpha 1 antitrypsin during cardiopulmonary bypass.

We serially measured concentrations of three protease inhibitors, antithrombin III, alpha 2 macroglobulin, and alpha 1 antitrypsin in patients with coronary artery and valvular heart disease during extracorporeal circulation. Assays for immunoreactive antiproteases and for functional antithrombin III were performed on plasma samples obtained at selected intervals before, during, and after cardiopulmonary bypass. Significant reductions of all protease inhibitors occurred at some time during cardiopulmonary bypass, although patterns of change were dissimilar for the two patient groups. A return toward preoperative levels was observed after cardiopulmonary bypass was discontinued, but antithrombin III remained diminished in the patients with coronary artery disease. The acute serial changes in this group of alpha globulins is evidence of their participation during the dynamic stress of extracorporeal circulation. Their timely intervention as serine protease antagonists deters sustained thrombogenesis and fibrinolysis during cardiopulmonary bypass.

Clinical experience with subxyphoid pericardial decompression.

Between 1971 and 1981, 108 patients with pericardial effusion were treated by subxyphoid pericardial decompression. 68 patients (63%) had local anesthesia, while general anesthesia was used in 40 (37%). The total group included nonspecific (viral) pericarditis in 35 patients (32.4%), uremic pericarditis in 30 (27.8%); and 20 patients (18.5%) with a malignant etiology, traumatic in ten patients (9.3%), six patients (5.6%) following radiation for malignant disease, and seven patients (6.5%) due to other causes. Echocardiography was diagnostic in all cases. Acute cardiac tamponade necessitated pericardiocentesis as an initial procedure in seven patients (6.5%). Subxyphoid pericardial decompression included drainage of the pericardial fluid and performance of a 5 X 5 cm pericardial window and biopsy of all patients. There were two (1.8%) operative deaths in the general anesthesia group but none in the local anesthesia group. There were no major complication in the local anesthesia group, but one patient in the general anesthesia group, who was severely hypertensive preoperatively, developed hemiplegia on the left side. There were five recurrences (4.6%) requiring total pericardiectomy at a later date. Subxyphoid pericardial decompression under local anesthesia was seen to be a safe and effective procedure for primary decompression and diagnosis of acute or chronic pericardial effusion.

Diagnosis and management of traumatic ventricular septal defect.

Four cases of ventricular septal defect secondary to stab wounds of the heart are presented. One of three patients arriving at the Emergency Department in shock and who were resuscitated required an emergency thoracotomy. These patients had immediate repair of their external cardiac wounds in the Operating Room. Cases 1 and 3 developed heart failure and loud systolic murmur postoperatively. Case 4 was treated with chest tube for a left hemothorax and developed heart failure after discharge. In Cases 1, 2, and 3, 2-D echocardiography detected and located a VSD. In Case 3 Doppler measurement showed elevated RV pressure (45 mm Hg) and decreased peak tricuspid to mitral flow ratio (0.36, normal = 0.6). All patients underwent cardiac catheterization. In Case 4 there was associated mitral regurgitation. Cases 1 and 3 had pulmonary to systemic flow ratios greater than 3:1. Cases 1, 3, and 4 underwent operative repair. In Case 1 the VSD was closed with a dacron patch, and in Cases 3 and 4 it was sutured with Teflon pledgets. In Case 4 a puncture wound of the mitral valve annulus was simultaneously repaired. All patients are alive but in Case 1 postoperative 2-D echocardiography demonstrated partial dehiscence of the patch which has not required reoperation and in Case 3 post-repair 2-D echocardiography and Doppler flow studies have shown an intact VSD repair. This series of post-traumatic VSD demonstrates its varying clinical presentation and the diagnostic and followup benefits offered by 2-D echocardiography, especially when combined with Doppler flow measures.(ABSTRACT TRUNCATED AT 250 WORDS)