Coronary artery bypass grafting in the octogenarian.

We have performed coronary bypass grafting in 25 patients 80 years of age or more. The patients' preoperative conditions were characterized by recent myocardial infarction (16/25, or 64%), obesity (15/25, or 60%), hypertension (14/25, or 56%), and left ventricular dysfunction (21/25, or 84%). There were no deaths in the hospital or within 30 days of operation (0/25, or 0%). Postoperative complications occurred in five cases (20%). Complications were leg incision infection (2/25, or 8%), urinary tract infection (1/25, or 4%), stroke (1/25, or 4%), and transient neurologic deficit (1/25, or 4%). There were no instances of reoperation for bleeding, perioperative myocardial infarction, renal failure, pulmonary failure, intraaortic balloon pump use, or sternotomy infection in these patients. Eleven patients (44%) were hospitalized for fewer than 10 days after operation, and all but two (23/25, or 92%) were discharged within 20 days after operation. All patients were followed up, and survival and New York Heart Association functional class were determined. Cumulative survival rate was 94% at 1 year and 88% at 5 years. The cumulative percent survival rate with class I or II function was 92% at 1 year and 80% at 5 years. No patient had recurrent angina.

Cardiopulmonary bypass in the presence of uncorrected coarctation.

We performed correction of intracardiac lesions in 10 patients with coarctation. All cardiovascular lesions were corrected except coarctation. Six patients had a large left-to-right shunt though a ventricular septal defect (VSD), two patients had left ventricular outflow obstruction, two patients had mitral insufficiency, and one patient had mitral stenosis. Arterial perfusion was through the ascending aorta. Urine output was 6.0 +/- 1.5 cc/kg/hr during cardiopulmonary bypass. There was no morbidity related to cardiopulmonary bypass or inadequate perfusion of the lower body, and left ventricular failure did not occur. One patient with Taussig-Bing abnormality and pulmonary vascular disease died postoperatively of right ventricular failure. Intracardiac repair with aortic perfusion in the presence of coarctation is a safe alternative to coarctation repair or combined procedures.

Comparison of outcomes with three atrial incisions for mitral valve operations. Right lateral, superior septal, and transseptal.

We compared the preoperative status, operative factors, and postoperative outcomes among patients having mitral valve operations with three atrial incisions. The incisions were right lateral (n = 66), superior septal (n = 46), and transseptal (n = 37). Differences in patient and operative factors among the groups were not predictors of adverse postoperative outcomes with multiple regression analysis. Postoperative pulmonary failure was less common in the superior septal group. Patients in the superior septal group more commonly required permanent pacemakers than those in the right lateral group. In patients with sinus rhythm before operation, sinus rhythm had returned before hospital discharge more commonly in those in the right lateral group (35 of 44, 80%) than in those in the superior septal group (18 of 28, 46%) or in the transseptal group (9 of 13, 69%). With multiple regression analysis the type of atrial incision was not a predictor of postoperative pulmonary failure or need for permanent pacemaker. Right lateral and transseptal atrial incisions were predictors of retention of sinus rhythm after operation. We conclude that the results of superior septal incision are comparable with those of other incisions except for a slightly greater risk of loss of sinus rhythm. One must weigh the technical advantages of the superior septal incision against the risk of loss of sinus rhythm.

The role of valve replacement in the treatment of fungal endocarditis.

The role of valve replacement in the treatment of fungal endocarditis has not been defined. The diagnosis of fungal endocarditis was made in 11 patients, 8 before death and 3 at autopsy. Nine patients were infected with Candida species, one with Torulopsis glabrada and one with Aspergillus. None of the 8 patients whose disease was diagnosed during life was cured despite up to 160 days of amphotericin B therapy. All required valve replacement for heart failure (1 patient), emboli (1 patient, or both (6 patients). We recommend early valve replacement for fungal endocarditis before the onset of heart failure and emboli.

Role of cardiac catheterization in infective endocarditis.

The benefits and hazards of catheterization and angiography were evaluated in 19 patients with acute aortic and/or mitral endocarditis and heart failure. In 14 patients (74%), the bedside diagnosis of valvular insufficiency and heart failure was proved correct. In three patients with both aortic and mitral valve disease, angiography (without hemodynamic measurements) was necessary to clarify the diagnosis. Angiography detected four aortic aneurysmal erosions that were unsuspected clinically, but missed three others. After angiography, heart failure worsened in two patients with severe progressive aortic insufficiency and one died. Thus, catheterization-angiography was of greatest value if more than one left-sided valve lesion was present, if extravalvular diseases mimicked heart failure, or if extravalvular infection was present. Patients with isolated, clear-cut mitral insufficiency usually do not need these diagnostic procedures, and they are probably contraindicated in patients with severe aortic regurgitation with rapidly progressing heart failure.

Predicting the need for prolonged ventilatory support in adult cardiac patients.

Forty-nine cardiac surgical patients had ventilatory function tests and measurements of maximum inspiratory (MIP) and maximum expiratory (MEP) pressures preoperatively. The differences between the values of various function tests were compared for patients requiring less than 24 hours of ventilator support and those requiring more than 24 hours. There was a significant difference in the mean values for the two groups in vital capacity (VC) first-second forced expired volume (FEV) midexpiratory flow between 50 and 75 (MMEF 50--75) and 75--85 percent of expired volume (MMEF 75--85), and MEP. The standard deviations of each of the variables were so large that the clinical usefulness was limited. However, when discriminant analysis was used for more than one variable, the combination of MMEF 75--85 and MEP predicted success or failure to wean in 24 hours correctly in 90 percent of instances. On the basis of these simple tests, patients predicted to succeed should be weaned from ventilator support on recovery from anesthesia. Those predicted to fail should be placed on intermittent mandatory ventilation (IMV) and should be weaned following a planned, logical process.

Effects of halothane and morphine sulfate on myocardial compliance following total cardiopulmonary bypass.

We evaluated the effect on diastolic myocardial compliance of halothane and morphine sulfate using 15 swine placed on total cardiopulmonary and right heart bypass with controlled aortic pressure, heart rate, and left ventricular preload. The animals were divided into three equal groups: (I) regional block anesthesia, (II) morphine sulfate (10 mg/kg), and (III) halothane anesthesia at 0.5%. Myocardial performance was evaluated on right heart bypass following a 30 minute period of total cardiopulmonary bypass before and after administration of the anesthetic agent by measuring stroke volume, left ventricular end-diastolic pressure, and left ventricular end-diastolic volume. All perfusions were at normothermia, at a hematocrit level of 30%, and at a normal arterial Po2. PCO2, and pH. Neither regional block nor morphine sulfate anesthesia significantly depressed the myocardium or changed diastolic compliance. Halothane, however, significantly decreased diastolic compliance so that stroke volume was less at a given left ventricular end-diastolic pressure, but not at a given left ventricular end-diastolic volume. The depression of stroke volume with halothane following cardiopulmonary bypass at equal filling pressures appears to be due primarily to a change in compliance rather than to a change in contractility.

Pulmonary artery partition: new method for correction of interrupted aortic arch.

We have successfully corrected interrupted aortic arch with ventricular septal defect by employing deep hypothermia and circulatory arrest, a median sternotomy incision, and a pulmonary arteriotomy. This simplified technique has the advantage of an abbreviated period of cerebral ischemia, with a relatively simple partitioning of the pulmonary artery.

Relative risk of aortic and femoral insertion of intraaortic balloon pump after coronary artery bypass grafting procedures.

We compared the preoperative, operative, and postoperative characteristics of patients who required balloon pumps after coronary artery bypass graft procedures to determine the relative risks of femoral and aortic insertion. The balloon pump was inserted into the ascending aorta when femoral insertion was not possible because of occlusive disease or small femoral arteries. Femoral insertion was performed in 81 patients and aortic insertion in 42 patients. Patients with aortic insertion were more likely to be small and female (p < 0.05) and were more likely to have carotid bruits and a history of strokes or transient ischemic attacks (p < 0.05). Death was more common in the patients with aortic insertion (18/42, 42.9%) than in those with femoral insertion (19/81, 23.4%) (p < 0.05), as calculated with single regression analysis. Route of insertion was not a predictor of operative death, according to multiple regression analysis. Leg complications were more common in patients with femoral artery insertion (23/81, 28.4%) than in those with aortic insertion (0/42, 0.0%) (p < 0.05). No sternal complications occurred in either group. New neurologic abnormalities were not significantly different between the patients with aortic and femoral insertion. Aortic insertion is a safe alternative to femoral insertion of intraaortic balloon pumps and is associated with fewer leg complications in small or diseased iliac and femoral arteries. The greater mortality rate with aortic insertion is related to greater comorbidity rate in these patients.

Interstitial hydrostatic pressures in patients undergoing CABG and valve replacement.

Using the Scholander-Hargens wick technique to measure interstitial fluid hydrostatic pressure (IFP) in thigh muscle (MIP) and subcutaneous tissue (SQIP), we have studied 12 patients undergoing cardiopulmonary bypass (CPB). Simultaneous measurements were made of serum total proteins (TP) and colloid osmotic pressure (COP). Bypass was carried out with a nonblood, noncolloid prime. In the postoperative period, colloid and blood were given which raised COP above prebypass levels (see Table II). MIP rises more with hemodilution than does SQIP and is less negative throughout. MIP rises faster when COP drops than does SQIP. These findings suggest that subcutaneous tissue interstitial space is loose and has a high compliance, whereas muscular tissue interstitial space is tight and has a low compliance. The increased pressure represents increase in fluid which is then removed promptly as COP is restored in the postoperative period. Experimental studies in animals show a response similar to MIP in the myocardium.

Preoperative correlates of impaired wound healing after saphenous vein excision.

Although major wound complications after saphenous vein excision are infrequent, we have found broadly defined impairment in leg wound healing to be relatively common. Wound healing impairment is defined in this study as inflammation, separation, cellulitis, lymphangitis, drainage, necrosis, or abscess necessitating dressing, antibiotics, or débridement before wound healing with complete epithelialization without eschar. Healing was impaired in 245 of 1047 patients (24.3%). Significant correlations were found between impaired wound healing and female sex (p less than 0.005), body mass index (obesity) (p less than 0.005), diabetes mellitus (p less than 0.005), left ventricular end-diastolic pressure greater than 15 mm Hg (p = 0.0074), arterial occlusive disease of the legs (p = 0.0124), and preoperative hematocrit value (p = 0.0491).

Correlates of preoperative hematocrit value in patients undergoing coronary artery bypass.

The patient's preoperative red cell volume and hematocrit value are among the strongest predictors of need for postoperative transfusion. We have determined the factors that correlate with preoperative hematocrit value. We performed multiple regression analysis with preoperative hematocrit value as the dependent variable. The factors that were significantly correlated with preoperative hematocrit value, in order of their decreasing contribution to variability, were sex, date of operation, preoperative hospital stay, weight, left ventricular end-diastolic pressure, age, smoking history, and recent myocardial infarction (less than 6 weeks). Factors that did not contribute significantly to predicting preoperative hematocrit value included ejection fraction, emergency operation, previous streptokinase use, number of coronary arteries diseased, body mass index (obesity), diabetes, height, body surface area, and history of percutaneous transluminal coronary angioplasty. The patient most likely to have a low preoperative hematocrit value can be characterized as a small, elderly, female nonsmoker with a recent myocardial infarction and elevated left ventricular end-diastolic pressure. The prevalence of low preoperative hematocrit value is increasing with time independent of other factors.

Results and patterns of perioperative myocardial infarction.

Myocardial injury during a variety of cardiac surgical operations was determined in 57 patients by serial electrocardiograms (ECG's), serial determinations of serum creatine phosphokinase (CPK), and perioperative and postoperative technetium-99m stannous pyrophosphate (PYP) scans. ECG evidence of injury developed in four patients, whereas positive localized injury by PYP scan developed in ten. Twenty-one patients had elevated CPK enzymes postoperatively. The localization of injury by PYP scan correlated with ECG evidence of infarction in only one of four patients. Localized left ventricular injury by PYP scan without new Q waves on the ECG was common (5/12) in patients undergoing aortic valve replacement with perfusion of the coronary arteries. The injury in patients with congenital heart disease occurred at sites of ventricular incision or suggested possible air embolization of the coronary arteries. Perioperative infarction is frequently segmental and nontransmural and occurs in patients with coronary, valvular, and congenital heart disease.

Extending the limits of hemodilution on cardiopulmonary bypass using stroma-free hemoglobin solution.

Ten swine were subjected to exchange transfusion to a hematocrit level of 5% with either stroma-free hemoglobin solution (SFHS) or 7% albumin solution. Myocardial performance, oxygen kinetics, and myocardial metabolism were subsequently examined using a perfused, in situ, right heart bypass, swine heart model with control of preload, afterload, and heart rate. Animals were tested during a control period (hematocrit = 30%) and following exchange transfusion with either solution to a hematocrit level of 5%. We found that myocardial performance following albumin solution exchange could not be sustained on right heart bypass, and these animals had a stroke volume of zero at a left ventricular end-diastolic pressure of 14 torr. SFHS animals had a significant drop in stroke volume at 14 torr following exchange (20 +/- 3 versus 10 +/- 4, p < 0.025), but this 50% performance level could be sustained. Coronary blood flow rose and myocardial oxygen consumption fell in both groups, although the statistically nonsignificant mean differences were less with SFHS. Arterial-coronary sinus oxygen difference fell significantly (p < 0.05) with albumin solution (7.3 +/- 0.8 versus 2.2 +/- 0.2) and nonsignificantly with SFHS (5.6 +/- 0.4 versus 4.1 +/- 0.7). Lactate production occurred in both groups, but was greater with albumin (34% +/- 6%) than with SFHS (3% +/- 16%). No changes in myocardial tissue gasses were noted in either group. Although myocardial performance decreased and some lactate production occurred with SFHS, we believe these comparative results provide promise in the eventual utilization of an oxygen-carrying agent such as SFHS to extend the limits of hemodilution to a hematocrit value of 5% or less.

Shunting, release, and distribution of nine and fifteen micron spheres in myocardium.

The shunting, release, and transmural distribution of 9 and 15 mu radioactive microspheres were compared in isolated hearts and intact hearts with and without adenosine triphosphate (ATP) vasodilation. ATP vasodilation caused increase shunting of 9 mu spheres but not 15 mu spheres (p less than 0.05). The transmural distribution of 9 and 15 mu spheres in left ventricle and septum were significantly different (p less than 0.01) and the difference was characteristic for the isolated heart and the nonvasodilated intact heart. There was no difference in distribution across the right ventricle. There appear to be significant differences in regional shunting as well as distribution in the intact heart. We found no systematic correction for comparing flows measured with 9 and 15 mu spheres.

Pulmonary endarterectomy for chronic thromboembolic obstruction: recent surgical experience.

Pulmonary thromboendarterectomy for chronic pulmonary emboli was performed on ten patients, ages 20 to 67 years, between July 1977 and June 1981. Five patients each were assigned to New York Heart Association functional classes III and IV. All patients had pulmonary hypertension and increased pulmonary vascular resistance. Obstruction beginning in the lobar arteries and involving more than 50% of the sequential arteries was present in all patients. Five patients had complete obstruction of a pulmonary artery. All patients had obstructive disease in both lungs. Pulmonary thromboendarterectomy was performed through central pulmonary arteriotomies and by use of deep hypothermia and circulatory arrest. Circulatory arrest was employed in one to four periods totaling up to 60 minutes. No neurologic deficit was observed. All patients developed reperfusion edema in the lungs. All patients had improvement in pulmonary hypertension and pulmonary vascular resistance. One patient died of lung failure in the late postoperative period. All survivors had improved lung function, with two functional classes in seven patients. Improvement in one equaled three functional classes and in one, by one functional class.

Trapping, nontrapping, and release of nine and fifteen micron spheres in dog kidneys.

Variations in the distribution of different size microspheres trapped within an organ depend upon regional variations in delivery or trapping of different size spheres. We have determined the intrarenal distribution of trapped 9 mu and 15 mu spheres, as well as their nontrapping and release in dog kidneys. More 15 mu spheres than 9 mu spheres are normally trapped in the outer cortex, and fewer 15 mu spheres than 9 mu spheres in the medulla. This is true whether the renal blood flow enters the organ through the hilum or through capsular collaterals with chronic renal artery occlusion. The differences in distribution are due to greater trapping of 15 mu spheres than 9 mu spheres in the outer cortex with subsequent greater delivery and trapping of 9 mu spheres than 15 mu spheres in the vasa rectae of the medulla. Axial migration of the larger 15m spheres with greater distribution to terminal branches of a vessel and less distribution to proximal branches does not explain these observations, because it is independent of the transcortical direction of blood flows. Studies with adenosine triphosphate (ATP) vasodilation show that 15 mu spheres are trapped to a greater degree than 9 mu spheres and that previously trapped 9 mu spheres may be released with ATP vasodilation. Nontrapping and release of microspheres are potential sources of error and are greater with 9 mu than 15 mu spheres.

Completion pneumonectomy and thoracoplasty for bronchopleural fistula and fungal empyema.

Achieving sterilization of the postpneumonectomy space and bronchial healing may be difficult when active granulomatous infection of the pleural space and lung parenchyma is present at the time of operation. Three patients with chronic bronchopleural fistula, fungal empyema, and fungal cavities of the remaining ipsilateral lobe were managed with one-stage completion pneumonectomy and modified eight-rib thoracoplasty. Two patients had infection with Aspergillus fumigatis and 1 patient had Coccidioides immitis. Two patients had received mediastinal radiation after prior upper lobectomy for carcinoma of the lung. Two patients were having massive hemoptysis at the time of pneumonectomy. Eight-rib thoracoplasty with suturing of the intercostal muscles to the bronchial stump was performed on all patients. In 2 patients a mass closure of hilar vessels and bronchus was used because of inability to individually close the vessels and bronchus due to ligneous scarring of the hilum. Antibiotic and antifungal irrigations into the operative area were used postoperatively. Chest tubes were left in place 6 to 8 weeks. All wounds healed primarily. Patients were alive without recurrent local infection or tumor at follow-up 3 to 13 years postoperatively.

Aortopulmonary anastomosis in patients with levotransposition.

A technique for approximating the right pulmonary artery to the aorta in levo (L) transposition is described. The anastomosis is placed high on the ascending aorta to avoid occluding the coronary circulation by the clamp during the anastomosis. It is in patients with occluded left side anastomoses or single right pulmonary arteries that the right-sided anastomoses are most useful in L-transposition.

Contractile fibroblasts (myofibroblasts) in a painful pacemaker pocket.

Electron microscopy of a painful fibrotic capsule around a cardiac pacemaker revealed classic myofibroblasts. These contractile fibroblasts share characteristics of both smooth muscle cells and fibroblasts and are thought to be the cellular cause of wound and scar contraction. The occurrence of pain and tenderness around a sterile pacemaker probably indicates contraction of scar tissue as the basis of the symptoms. This scar tissue is similar to that seen around other large inert implants placed in the thoracic tissue.