Intraaortic balloon counterpulsation in patients in cardiogenic shock, medically refractory left ventricular failure and/or recurrent ventricular tachycardia.

Of the 27 patients described, 23 were in cardiogenic shock, 2 had severe left ventricular failure, and 2 had medically refractory ventricular tachycardia. Utilizing intraaortic counterpulsation, adequate systemic blood pressure was initially restored in 19 patients. Nine of these were subsequently weaned from circulatory assistance, but only three were discharged from the hospital and are currently alive. The remaining 10 patients who derived initial benefit from circulatory assistance were balloon-dependent in that they could not be weaned from circulatory assistance. Eight of these patients subsequently underwent cardiac catheterization; four had inoperable disease. The remaining four patients underwent surgery for either resection of the area of infarction and/or for myocardial revascularization; only one survived to subsequently leave the hospital. Ventricular volumes were abnormal and ejection fractions were below 30 per cent in all the patients in cardiogenic shock except one who underwent cardiac catheterization and ultimately died. Ejection fractions were greater than 30 per cent in the two patients with cardiogenic shock who were weaned from balloon support and survived to leave the hospital without surgery. Both of these patients had inferior myocardial infarction. The data obtained from this experience suggest that intraaortic counterpulsation is a very useful adjunct to currently existing medical measures to treat both cardiogenic shock and medically refractory left ventricular failure but that most patients have such extensive disease that they can neither be weaned from balloon support nor undergo successful infarctectomy or myocardial revascularization.

Long-term functional results of surgery for coronary artery disease in patients with poor ventricular function.

Thirty-two patients with coronary artery disease and an ejection fraction (EF) below 0.40 had coronary bypass and/or left ventricular aneurysm (LVA) resection. Twenty-four patients had a previous infarction, 12 had congestive heart failure (CHF), and left ventricular end-diastolic pressure averaged 15 mm. Hg. Nineteen patients had three-vessel involvement and there was an average of 2.4 vessels involved per patient. Bypass was accomplished on 87 per cent of vessels; 11 patients had resection of LVA; 11 had coronary endarterectomy. There were no hospital deaths, 63 per cent of the patients were improved, and 56 per cent were able to return to work or full activity. There were five late deaths (16 per cent). There was good functional improvement in 83 per cent of the survivors, followed 1 to 4 years. We believe that patients with poor ventricular function due to severe coronary artery disease should not categorically be denied surgery, and that operation can be done with a low hospital mortality rate and good functional results.

Heparinless femoral venoarterial bypass without an oxygenator for surgery on the descending thoracic aorta.

Heparinless femoral venoarterial bypass without an oxygenator has been used for surgery in 11 patients with aortic lesions requiring cross-clamping of the descending thoracic aorta. Mixed venous blood circulates in the lower half of the body and proximal hypertension is controlled. Surgical time is not rushed, and the bleeding of heparinization is avoided. All patients are well.

The management of descending thoracic aortic aneurysms using heparinless femoral venoarterial bypass.

In an attempt to use the benefits of controlled circulatory bypass, while avoiding systemic heparinization and bypass circuitry placed in the operative field, we used heparinless femoral venoarterial bypass without an oxygenator for resection of aneurysms of the descending thoracic aorta. Since 1974 we have applied this technique on 29 patients with excellent results (survival 27-29, 93 percent). Using PPG tubing, mixed venous blood was drained from the right atrium by way of a long catheter inserted via the femoral vein, and returned to the femoral artery by a roller pump. Advantages include distal aortic perfusion, a safety factor in avoiding spinal cord ischemia; preload control, helpful in managing proximal aortic hypertension; avoidance of heparinization; an operative field free of bypass circuitry; and the operation can be performed in an unhurried fashion.

Internal configuration of saphenous-coronary anastomoses as studied by the cast-injection technique.

A study of the internal configuration of saphenous vein--to--coronary artery anastomoses was undertaken to examine the effect of technical factors. One hundred fifty anastomoses were constructed in isolated swine hearts and epoxy-resin casts were made of the anastomoses by pressure-injection. The effects of interrupted sutures, continuous suture, vein tailoring, vein-to-artery size ratio, and end-to-side and side-to-side anastomoses were evaluated. We made several observations: (1) The external appearance of an anastomosis is not a reliable indicator of internal configuration. (2) Interrupted suturing consistently produces an internal configuration with minimal deformity. (3) Unless special precautions are taken with continuous suturing, severe deformities may occur. Very fine suture spacing and knotting distal corner sutures are recommended. (4) Proper vein-to-artery size ratio and "cobra-head" vein tailoring are desirable. (5) Side-to-side anastomoses are similarly significantly affected by suture techniques, vein graft size, venotomy size, and orientation. The study of the internal configuration of saphenous-coronary anastomoses is a simple and readily available method which should be useful to all coronary surgeons in assessing and perfecting their techniques.

Myocardial protection: a comparison of cold blood and cold crystalloid cardioplegia.

Two hundred seven consecutive patients were randomized into four groups based on left ventricular end-diastolic pressure and subsequently into groups receiving crystalloid cardioplegia or blood cardioplegia. Hemodynamic data and enzymatic evidence of myocardial ischemia were examined postoperatively. We found slight but significant improvement in the blood cardioplegia group regarding left ventricular stroke work index. Similarly, the levels of creatine kinase and serum glutamic oxaloacetic transaminase were slightly but significantly better with blood cardioplegia. We believe that the technique of blood cardioplegia offers a slight but statistically significant advantage.

Omental pedicle grafting in the treatment of postcardiotomy sternotomy infection.

Postcardiotomy sternal infection occurred in 20 (2%) of 1007 patients undergoing cardiac surgery between September 1985 and December 1987, a 10-fold increase over the preceding 33 months (4 [0.24%] of 1627 patients). Cultures were sterile in 5 patients and yielded staphylococci in 12 and a variety of bowel organisms in 3. The cause for the increased occurrence of sternal wound infection is unclear after multivariate analysis, although infections have precipitously dropped subsequent to changing to cefuroxime sodium antibiotic prophylaxis. Treatment has evolved to appropriate antibiotics and early débridement of involved sternum and cartilage. Rewiring the sternum is not attempted. If gross purulence is not present, primary closure is accomplished using muscle flaps (2 patients) or omental pedicle grafts (17 patients). In the presence of gross purulence, the wound is packed open for 5 days and then closed in the above fashion. Two patients required skin grafts for primary closure. The omental pedicle flap is preferred due to simplicity and improved coverage of the sternal defect inferiorly. Nineteen patients healed primarily. A superficial wound infection was drained in 1 patient. Midline incisional hernias developed in 3 muscular patients. Omentum is now harvested through a left subcostal incision. Hospital stay was under 2 weeks in 13 patients. One death occurred due to multisystem failure prior to completion of wound closure. In our experience, early sternal débridement and omental pedicle grafting with primary closure is appropriate therapy for postcardiotomy sternotomy infections. The presence of gross purulence may require 5 days of open packing prior to omental grafting. No significant complications occurred, and mortality was low. A left subcostal incision for omental harvesting is utilized to avoid the occurrence of delayed incisional hernias.

A comparative study of IPPB, the incentive spirometer, and blow bottles: the prevention of atelectasis following cardiac surgery.

Following cardiac operations, 145 patients were treated with either intermittent positive-pressure breathing (IPPB), blod bottles, or an incentive spirometer in an attempt to alter the incidence of atelectasis. Pulmonary complications occurred in 30% of the patients receiving IPPB, 15% of those using an incentive spirometer, and 8% of those using blow bottles. Gastrointestinal side-effects occurred in 20% of the IPPB group and were rare in other groups. The cost of IPPB is also considerably greater than either incentive spirometry or blow bottles. IPPB is not essential to prevention of atelectasis in postoperative cardiac surgical patients and may be inferior to other methods.

A technique for avoidance of hypothermia during prolonged mechanical circulatory support with centrifugal pumps.

Systemic hypothermia became a major problem in one of our patients undergoing postcardiotomy mechanical circulatory support with a centrifugal pump. We have developed a technique to prevent systemic hypothermia in this setting by applying an adapted topical cardiac cooling device to the centrifugal pump heads.

Internal banding for palliation of truncus arteriosus in the neonate.

A method for surgically limiting pulmonary blood flow in the critically ill neonate with truncus arteriosus is described. Two recent cases utilizing this technique are presented. Comparisons are made between this and other palliative surgical procedures used in truncus arteriosus.

Vascular complications of intraaortic balloon counterpulsation.

Between February 1973 and December 1986, 4,787 patients underwent open heart surgery at Samuel Merritt Hospital. Retrospective analysis revealed 395 (8 percent) consecutive patients who required hemodynamic support with the intraaortic balloon pump. Thirty percent of the patients had preoperative placement, 56 percent needed the balloon in order to wean from cardiopulmonary bypass, and 14 percent required placement in the postoperative period. The intraaortic balloon pump was instituted with multiple techniques and insertion sites. Three hundred eighty-three balloon catheters (96 percent) were inserted through the groin by surgical cutdown or a percutaneous approach. The remaining devices were inserted through the aortic arch. A 12 F. catheter was utilized in 239 patients (61 percent) and a smaller 10.5 F. catheter was placed in 156 patients (39 percent). The hospital mortality rate was 47 percent. Seventy-two of the 395 patients (24 percent) sustained vascular complications related to balloon use. Major complications occurred in 43 patients. Twenty-nine patients sustained minor complications that resolved spontaneously with balloon removal. Risk factors evaluated included patient gender, New York Heart Association class, catheter size, method of introduction, duration of counterpulsation, and presence of symptomatic peripheral vascular disease. Since percutaneous placement was associated with a significant decrease in complications, we concluded that use of the smaller 10.5 F. catheter placed percutaneously is the safest means of employing the intraaortic balloon pump. A monitoring line is placed percutaneously through the femoral artery in high-risk patients before operation. This allows easier access for intraaortic balloon pump placement in hypotensive patients. The presence of a clinical history of peripheral vascular disease was also a highly significant risk factor for vascular complications. Other risk factors increasing the likelihood of vascular compromise included catheter size and duration of counterpulsation.

Closure of bronchopleural fistulas by an omental pedicle flap.

Bronchopleural cutaneous fistulas are a serious problem that are difficult to treat with any assurance of success. Thoracoplasty, muscle pedicle grafts, and attempts at reclosure have been used with limited success. We have used the omental flap technique in the management of five patients with bronchopleural cutaneous fistulas. In our patients and in four cases in the literature, the success rate has been 100 percent. The omental pedicle flap is a simple way to close bronchopleural fistulas. It avoids extensive chest wall dissection and destruction in patients who often have marked respiratory embarrassment and other underlying disease. The results have been excellent.

Autologous blood retrieval in thoracic, cardiovascular, and orthopedic surgery.

A significant amount of red blood cells were conserved with use of the Cell Saver in cardiac surgery patients and in some orthopedic and vascular surgery patients. No major complications have been associated with its use in our cases. Our results are similar to those of others who have reported on the use of this device. In the cardiac surgery patients we observed significant serum protein losses which had to be replaced. We recommend the use of intraoperative albumin to help maintain adequate urinary output and hemodynamic stability.

Intravenous leiomyomatosis with cardiac extension.

A woman with intravenous leiomyomatosis experienced syncope 7 years after a total abdominal hysterectomy and oophorectomy for a uterine fibroid. The workup revealed a tumor that extended from the iliac veins to the right ventricle. It was totally removed under cardiopulmonary bypass. One year later, the patient was found to be asymptomatic and without evidence of tumor recurrence.