Management of ventricular perforation during revascularization of an intramyocardial left anterior descending artery.

Ventricular perforation during exposure of an intramyocardial left anterior descending artery (LAD) in preparation for coronary artery bypass grafting is a known surgical complication. In this report, we discuss the management of this complication which avoids closure of the LAD and a myocardial infarction.

Simple technique to preserve the LSVC during reoperative orthotopic heart transplant.

Increasingly, patients undergo heart transplant after previous heart surgery. In patients with a persistent left superior vena cava (LSVC), the preferred technique, preservation of drainage via the native coronary sinus, can be difficult in reoperative cases due to adhesions. We report a technique simplifying this operation in such a patient.

Development and Preliminary Psychometric Testing of the Drake Atrial Electrogram Assessment Survey: DAEGAS.

BACKGROUND: Critical care nurses who care for postoperative cardiac surgery patients need such specialty knowledge as atrial electrograms (AEGs). An inadequate audit trail exists for psychometric performance of instruments to measure knowledge of AEGs. OBJECTIVES: The aim of this study was to revise a previously tested instrument and assess evidence for content validity (content validity index), internal consistency (Cronbach α), and stability (correlation coefficient, r) reliability against the a priori criterion of 0.80. METHODS: The multiple-choice response, self-administered, paper-and-pencil instrument was revised to 20 items and named the Drake Atrial Electrogram Assessment Survey (DAEGAS). A panel of 6 AEG experts reviewed the DAEGAS for content validity evidence. The instrument was further revised to 19 items (13 knowledge and 6 AEG interpretation) and tested with 76 critical care nurses from the greater Houston metropolitan area. RESULTS: The content validity index was 0.93. Cronbach α was .51, and test-retest r was 0.74. Cronbach α increased to .60 and r was 0.73 with removal of 3 items: 2 items with a negative item-total correlation and 1 item that was transitioned to a sample question. DISCUSSION: Content validity evidence exceeded the a priori criterion. Internal consistency and stability reliability estimates did not meet the criterion, albeit the latter met the criterion recommended by psychometricians for a new instrument. Recommendations include further development of the DAEGAS to improve internal consistency estimates and testing for evidence of other forms of validity. Reliable and valid assessment of critical care nurse knowledge of AEGs will require improved psychometric performance of the DAEGAS.

"Snake-jaw" graft for aortic valve exposure during LVAD implant.

We report a simple technique of LVAD outflow anastomosis as patch closure of a standard aortotomy during left ventricular assist device (LVAD) implant. Benefits are a single aortotomy, a low graft leaving ample native aorta for transplant, a wide-open LVAD outflow, and excellent aortic valve exposure.

Integrating resuspension with remodeling: early results with a new valve-sparing aortic root reconstruction technique.

BACKGROUND AND AIM OF THE STUDY: Currently, two different valve-sparing aortic root reconstruction methods are utilized, namely reimplantation and remodeling. Herein are reported the authors' early results with a new technique that integrates the two procedures. METHODS: Seven patients (age range: 25-69 years) underwent valve-sparing aortic root replacement with a new technique that integrates the principles of the David and Yacoub operations. The preoperative aortic root sizes were 4.9 to 7.0 cm, and six patients had aortic regurgitation (grade 1+ to 3+). Surgery was divisible into four stages: (i) External subcommissural (downsizing) annuloplasty; (ii) graft sizing and valve competency assessment with saline squirt test; (iii) sewing the individual tongues of a hand-scalloped Hemashield graft to the annular tissue with subvalvular pledgeted mattress sutures; and (iv) running suture lines to the commissural aspects of the aortic wall, followed by coronary reimplantation. RESULTS: All patients survived surgery. Intraoperative transesophageal echocardiography showed trace aortic incompetence (AR) in five patients, and mild or moderate AR each in one patient. Over a two-year period the technique was improved to the above-described, four-stage approach, which resulted in only trace AR in the final three patients. Early serial transthoracic echocardiography confirmed stable root dimensions and no progression of AR, except in an early patient. CONCLUSION: In the described technique, graft sizing is strictly tied to early intraoperative valve competency testing after an initial reconstruction within the native aortic root. The operation is then converted into a modified remodeling by suturing the triple-tongued (Yacoub) graft to the true aortic annulus with subannular pledgets (David principle). The operation involves significantly less dissection around the aortic root, and the entire scalloped annulus is stabilized in between the graft material and pledgets.

Tricuspid Septal Leaflet Detachment for Ventricular Septal Defect Repair in Adults.

We report a 21-year-old patient with a ventricular septal defect (VSD) with an embolic vegetation on the tricuspid valve using a technique of septal leaflet detachment to facilitate the repair of the VSD. Although described in the pediatric patients, this technique has not been reported in adults. The technique of septal leaflet mobilization is described, along with other techniques of tricuspid leaflet mobilization that aid in VSD visualization and repair. Tricuspid leaflet detachment has application for adult surgeons repairing perimembranous, postinfarction, and iatrogenic VSD encountered in resection of subaortic stenosis.

Streptococcus viridans endocarditis from tongue piercing.

Body piercing and tattooing have undergone a revival in popularity. We present the case of a 27-year-old man with a recent tongue piercing and infective endocarditis of the aortic valve. He was treated with a 6-week course of intravenous antibiotics, but eventually required a Ross procedure for progressive aortic insufficiency.

T-modification of sternotomy to accommodate a low-lying tracheostomy.

A low-lying tracheostomy can complicate a sternotomy for coronary artery bypass grafting. A modified "T" exposure, transecting the manubrium at the first intercostal space, can be utilized to maintain sternoclavicular architecture and avoid injury to the tracheostomy at the sternal notch.

Mitral regurgitation following acute myocardial infarction.

Mitral valve regurgitation (MR) is a frequent Doppler echocardiographic finding in patients after acute myocardial infarction (AMI) and an independent predictor of long-term cardiovascular mortality. Reported risk factors include advanced age, prior myocardial infarction, infarct extension, and recurrent ischemia. During the early phase of AMI, transient ischemic MR is common and rarely causes hemodynamic compromise. However, when several chordae tendineae or a papillary muscle ruptures, acute left atrial and ventricular volume overload ensues, leading to abrupt hemodynamic deterioration with cardiogenic shock. Auscultation may be unrevealing due to decreased turbulence. Hence, the importance of a high index of suspicion for acute MR in any patient with acute pulmonary edema in the setting of AMI, especially if left ventricular systolic function is well preserved. Later, ventricular remodeling may lead to MR through annular dilatation or papillary muscle migration with malcoaptation of the leaflets. The widespread availability, ease of use and non-invasive nature of Doppler echocardiography have made it the standard diagnostic tool for detecting MR. Mechanical reperfusion of the infarct-related artery seems to be superior to fibrinolysis in decreasing its incidence acutely and in the long run. Nevertheless, when acute severe MR occurs, unless rapidly diagnosed and treated, this dreaded complication is associated with high morbidity and mortality. Prompt surgical intervention after hemodynamic stabilization is essential to ensure a good short-term and long-term prognosis. This review discusses the incidence, long-term prognosis, associated risk factors, complex pathophysiology, time of occurrence, clinical manifestations, diagnosis, and management of patients with MR after AMI.