Pulmonary embolectomy in the neonate.

Pulmonary embolectomy under cardiopulmonary bypass was performed on a six-day-old infant. The clinical presentation suggested cyanotic congenital heart disease secondary to pulmonary stenosis or atresia with intact ventricular septum. At operation, a large blood clot was found completely occluding a normal pulmonary valve. The use of prostaglandin E1 facilitated cardiac catheterization and emergency surgery.

Surgical resection of giant metastatic leiomyosarcoma of the heart.

A 44-year-old woman underwent a hysterectomy for leiomyosarcoma in 1969. Cardiac invasion was detected in 1981 but the tumor was considered inoperable. In 1985, 16 years after hysterectomy, malignant tamponade developed as a result of a massive tumor arising from the left ventricle. Emergency decompression by median sternotomy and tube thoracostomy was followed a week later by tumor resection and simultaneous excision of a lung metastasis with the aid of cardiopulmonary bypass. The cardiac tumor weighed 719 gm. A residual pelvic tumor found on a computed tomographic scan was subsequently removed. She is alive and well 22 months after the operation. Aggressive surgical resection of cardiac and other metastases of this slowly growing tumor can be lifesaving.

Pulmonary artery balloon counterpulsation for acute right ventricular failure.

The development and availability of right ventricular assist devices has not kept pace with the evolution of devices designed to mechanically support the systemic circulation. This report describes the application of the counterpulsation concept to the pulmonary circuit to unload the failing right ventricle and augment pulmonary blood flow. Conventional, widely available balloon pumping equipment was employed. Use of this double balloon pump system enabled a patient to be weaned from cardiopulmonary bypass after all other measures had failed. Other relevant potential clinical applications for this technique are discussed.

Ventricular septal defect and aortic insufficiency. Surgical treatment.

Twenty-five patients with ventricular septal defect (VSD) associated with aortic insufficiency (AI) have been since 1964. Of these patients, one died suddenly without operation; in 2 patients, AI developed in the late postoperative period following VSD closure; and in 3 others, AI developed shortly after VSD closure. The remaining 19 patients are discussed in detail. The VSD was subpulmonic in 13 (68 per cent) and subcristal in 6 (32 per cent). Primary suture of the VSD was undertaken in 13 patients and patch closure in 6. Seven patients had aortic valvuloplasty and 2 had aortic valve replacement. There were no surgical deaths, and the long-term follow-up shows that VSD closure alone has been sufficient to arrest progression of AI in patients with mild insufficiency, particularly in those with subpulmonic VSD. Valvuloplasty, when necessary, was more effective when done at an early age.

Acute thrombotic obstruction with Björk-Shiley valves: diagnostic and surgical considerations.

Eight patients have had thrombotic obstruction of a prosthetic valve since 1971, six mitral valves and two aortic. All eight patients had a Björk-Shiley valve. During the same period 159 Björk-Shiley valves were placed, 85 in the mitral and 74 in the aortic area. This represents a valve thrombotic occlusive incidence of 4.4 percent in our series, 5.9 percent of mitral and 2.7 percent of aortic prostheses. Among the six patients with mitral prostheses only one survived. The two patients with occluded aortic valves survived. The onset of symptoms was very abrupt in most patients and progressed very rapidly. Acute pulmonary edema was observed in five patients. Anticoagulation was considered inadequate in all patients. Aspirin or dipyridamole was being used in seven patients at the time of thrombosis. The data indicate a high frequency of thrombotic occlusion of Björk-Shiley valves in the absence of full anticoagulation with warfarin derivatives and emphasizes the urgent need for surgery once valve thrombosis is suspected.

Mechanical support: assist or nemesis?

Our 6-year experience with ventricular assist devices was reviewed to determine variables associated with improved survival. Forty-three patients (mean age 62 +/- 14 years) were supported after balloon pumping and pressors proved inadequate. Twenty-eight patients could not be weaned from cardiopulmonary bypass, 12 patients deteriorated in the intensive care unit after cardiac surgery, and three had a bridged to transplantation. Overall, 47% (20/43) of patients could not be weaned from the ventricular assist devices, and 26% (11/43) were weaned but died before discharge, resulting in a hospital mortality rate of 72% (31/43). The remaining 28% (12/43) of patients were discharged and have survived 9 to 62 months. Early institution of ventricular assist devices (p less than 0.01), use of biventricular support (p less than 0.01), use of ventricular assist devices as a bridge to transplantation (p less than 0.05), and increased operator experience (p less than 0.05) were associated with improved survival. When patient and disease-related variables were analyzed, only age less than 60 years (p less than 0.01) and unexpectedly preoperative myocardial infarction associated with shock (p less than 0.05) were related to improved survival. Death was caused by insufficient ventricular recovery, stroke, multiple organ system failure, sepsis, or a combination of these complications. During long-term follow-up, two patients have died of congestive heart failure, and one is significantly impaired from a stroke. Two other patients are functional class III and seven patients are class I. Although hospital mortality was high (72%), the use of ventricular assist device support resulted in overall "long-term" survival of a significant percentage (28%) of patients, 47% (8/17), in the past 12 months, all of whom would have died without it. Therefore we currently recommend a trial of ventricular assist devices support for most patients who fail to be weaned from cardiopulmonary bypass, deteriorate in the perioperative period, and as a bridge to transplantation. Long-term survival is determined by the complications from ventricular assist devices support and functional status of the remaining myocardium.

Clinical durability of the Hancock porcine bioprosthetic valve.

The principal feature of the Hancock xenograft bioprosthesis which remains to be completely defined is long-term durability. This report provides extended data regarding valve durability derived from a data base of 1,407 patients (707 aortic [AVR] and 700 mitral [MVR] replacements) who received Hancock bioprostheses between 1971 and 1979; cumulative duration of follow-up was 1,732 patient-years for AVR and 1,843 for MVR patients, with a maximum follow-up duration of 8.4 years. One hundred seventy-nine patients were followed for more than 5 years and 67 for more than 6 years. Valve failure was defined on the basis of one or more of the following criteria: (1) postoperative development of a new regurgitant murmur, (2) thrombotic valvular occlusion, (3) infective endocarditis resulting in reoperation or death, and (4) hemodynamic valvular dysfunction confirmed by catheterization and resulting in reoperation or death. Twenty-one such failures occurred among all AVR patients and 23 among all MVR patients. The actuarial probability of freedom from valve failure (all causes) was 95.4% +/- 1.2% (+/- SEM) for adult AVR patients 5 years postoperatively and 90.9% +/- 2.6% for adult MVR patients 6 years postoperatively. The probability of freedom from primary tissue failure in adults was 99% +/- 1% in AVR patients at 5 years and 94.3% +/- 2.4% in MVR patients at 6 years. The linearized incidence of primary tissue failure in children (< 15 years old) was 9.8% per patient-year (combined AVR and MVR patients), compared to 0.2% per patient-year among all adult patients in the analysis. The combined actuarial incidence of primary tissue failure among adults with AVR and MVR was 98.6% +/- 0.7% at 5 years and 94.2% +/- 2.3% at 6 years; thus there appears to be a slight acceleration in the rate of valve tissue failure between 5 and 6 years after operation. The incidence of failure, however, remains acceptably low through 6 years of follow-up, and continued clinical use of the xenograft bioprosthesis seems warranted.

Concomitant resection of ascending aortic aneurysm and replacement of the aortic valve: operative and long-term results with "conventional" techniques in ninety patients.

We reviewed a consecutive series of 90 patients undergoing concomitant resection of ascending aortic anerysm and aortic valve replacement (AVR) utilizing noncomposite "conventional" techniques in order to assess the early and late results, to define limitations of this operative approach, and thereby to clarify the indications for composite reconstruction of the aortic root. Mean age was 55 years. Twenty percent had Marfan's syndrome, and 13% had aortic dissections. The cause of the aneurysm was dissection in 13% of cases, syphilis in 11%, atherosclerosis in 9%, and degeneration (with or without cystic medionecrosis) in 67%. Follow-up averaged 3.8 years and extended to 11.5 years maximum. AVR and complete excision of the aneurysm (preserving small tongues of aortic wall circumscribing the coronary artery ostia) coupled with tubular graft replacement of the ascending aorta were performed. Nineteen percent of patients required individual technical modifications relating to the coronary arteries. Operative mortality rate was 13%, with the majority of deaths being due to cardiac causes. Contemporary (1975 to 1978) operative mortality rate was 4.3%. Seven percent required re-exploration for hemorrhage and 2.4% had perioperative myocardial infarctions. Late functional results were generally good (average N.Y.H.A. Class 1.4). Late thromboembolism, angina, myocardial infarction, and congestive heart failure occurred at linearized rates of 3.4% per patient-year, 4.9% per patient-year, 1.1% per patient-year, and 5.2% per patient-year, respectively. No prosthetic valve endocarditis, graft infection, or recurrent aneurysms of the aortic root were observed. Late reoperation was necessary in eight patients (3% per patient-year), but reoperation for disease confined to the ascending aorta accounted for only three of these cases (1.1% per patient-year). Overall actuarial survival rates were 67% +/- 5% at 5 years and 50% +/- 9% at 10 years; survival rates for the 78 operative survivors were 77% +/- 5% and 57% +/- 10% at the same time intervals, respectively. Only one late death could be attributed to complications arising in the reconstructed aortic root. These results confirm that such simple, noncomposite techniques are safe, portend minimal risk of late complications and the attendant necessity for reoperation, and provide satisfactory long-term survival. We believe that composite techniques should be primarily reserved for selected cases of advanced necrotizing prosthetic or natural endocarditis.

A surgical approach for S,L,L single ventricle incorporating total right atrium--pulmonary artery diversion.

Patients with single ventricle and unfavorable anatomy for partitioning procedures have been considered inoperable. Such was the case in two patients with single ventricle and subaortic inverted (hypoplastic) infundibulum associated with subaortic obstruction and levo-transposition of the great vessels (S,L,L). Both had undergone pulmonary artery banding in infancy and presented 11 and 14 years later, cyanotic and severely incapacitated. Both patients were treated surgically by resection of the subaortic obstruction, patch closure of the right artrioventricular valve, closure of the proximal pulmonary artery, and diversion of systemic venous flow through a xenograft valved conduit from the right atrium to the distal pulmonary artery. Early postoperative complications included atrial dysrhythmias and right-sided congestion. The first patient, who had massive cardiomegaly and complete heart block preoperatively, developed congestive failure 20 months postoperatively. The second patient has an excellent functional result and is leading a normal life 1 years after operation. This procedure may be of value for patients with single ventricle in whom corrective ventricular septation is considered too risky or technically unfeasible.

Comparative study of prophylactic antibiotics in cardiac surgery. Clindamycin versus cephalothin.

A randomized, prospective study of the relative effectiveness of clindamycin versus cephalothin was performed in 263 adult patients having cardiac surgery from September, 1977, to August, 1978. There were no statistically significant differences in frequency of postoperative infections in these two antibiotic groups. Wound infection developed in 6.5 percent of the cephalothin group and 3.2 percent of the clindamycin group. Urinary tract infection developed in 5.6 percent of the clindamycin group and 2.1 percent of the cephalothin group. Four bacteremic episodes occurred in the clindamycin-treated patients, and one episode of bacteremia occurred in a cephalothin-treated patient. No cases of endocarditis occurred during the study. Clindamycin deserved consideration as an alternative prophylactic agent to cephalothin for cardiac surgery.

Cost reduction by combined carotid endarterectomy and coronary artery bypass grafting.

A significant cost reduction is likely if patients who require coronary artery bypass grafting with significant carotid stenosis have simultaneous carotid endarterectomy and bypass grafting, provided risk is not increased. To investigate this issue, we retrospectively identified cases from February 1977 to May 1994 with first-time isolated carotid endarterectomy, coronary bypass, or combined procedures. In the isolated carotid endarterectomy population, median age was 69 years and 58% (85/146) were male, as compared with 68 years and 68% (68/100) male in the combined group; median age of the coronary bypass cohort was 65 years and 76% (381/500) male. A significantly higher percentage of patients in the coronary bypass versus combined group were in New York Heart Association functional class IV. In the combined group there was a significantly higher incidence of older age, diabetes, hypertension, hyperlipidemia, renal failure, and congestive heart failure. There was no difference among the three groups with respect to hospital mortality (0%, 3.4%, and 4.0%, respectively) and permanent stroke (0.7%, 1.2%, and 0%, respectively). Hospital costs were $4,896, $10,959 and $11,089, respectively, with a savings of $4,766 (30%), and Medicare hospital reimbursement was $8,575, $23,071, and $23,071, respectively, with a savings of $10,077 (25.3%). Thus, in appropriate patients, a combined procedure is cost effective, eliminating a second surgical procedure and the cost of the postoperative stay (3.7 +/- 2.4 days) associated with isolated carotid endarterectomy. Risk of permanent stroke or death is not increased.

Hemodynamic and clinical comparison of the Hancock modified orifice and standard orifice bioprostheses in the aortic position.

Bioprosthetic aortic valve replacement in patients with a small aortic root has been associated with postoperative transvalvular gradients. A modified orifice Hancock xenograft bioprosthesis has been developed and is purported to increase significantly the effective orifice area (as evaluated by in vitro testing) compared to the standard orifice Hancock bioprosthesis. To assess the in vivo differences, we compared 481 patients with standard orifice prostheses with 156 patients with modified orifice prostheses. Postoperative catheterization was performed in 24 patients with modified orifice (valve diameters 19 to 25 mm) with 14 with standard orifice valves (valve diameters 21 to 25 mm). Actuarial rates of survival, valve failure, endocarditis, and thromboembolism did not differ significantly between the two subgroups. Peak aortic valve gradients on the whole were less in the modified orifice subgroup than in the standard origice subgroup (12 +/- 1 torr versus 20 +/- 6 torr [mean +/- SEM]), but the difference was not statistically significant (p greather than 0.05). The calculated in vivo aortic valve areas were slightly, but insignificantly, greater in the modified orifice subgroup than in the standard orifice subgroup (p greater than 0.05). These in vivo data partially corroborate the in vitro findings of increased effective orifice area and internal-to-external diameter ratio for the modified orifice bioprosthesis. The hemodynamic differences between the two valve types are small, however, and the putative clinical advantages inherent in the use of the modified orifice bioprosthesis remain to be completely defined.

Successful mechanical circulatory support for noncoronary shock.

Mechanically assisted recovery from shock and long-term survival of nontransplant patients with acute noncoronary myocardial decompensation have not been previously reported. We treated nine patients (aged 8 to 53 years) who were referred with acute nonischemic cardiogenic shock (pulmonary capillary wedge greater than 20, cardiac index less than 1.5 L/min/m2, mean blood pressure less than 60 mm Hg, ejection fraction less than 0.3%). Eight patients had viral prodromes, and one patient was peripartum. All patients' lungs were mechanically ventilated, and pharmacologic support failed in all patients. Two patients received steroids. All received mechanical circulatory support. Seven were initially supported with intraaortic balloon counterpulsation pumps. Two patients recovered with intraaortic balloon counterpulsation pumps alone (3 days and 4 days). Four patients received left ventricular assist devices (3, 7, 10, and 79 days), and two received biventricular support devices (10 days and 14 days). One patient was supported with extracorporeal femoral vein-to-femoral artery bypass for 6 days. Four patients required dialysis (4 days to 5 weeks). Seven patients underwent myocardial biopsies, of which three demonstrated acute myocarditis. All patients recovered ventricular function (ejection fraction greater than 0.55%), and all are New York Heart Association functional class I, 7 months to 4 1/2 years after support. Mechanical circulatory assist devices may be lifesaving for patients with acute nonischemic myocardial decompensation. Patients should be supported for at least 2 weeks before transplantation is considered.

Postinfarction ventricular septal defect: an argument for early operation.

We reviewed our experience with 43 consecutive patients who underwent operations for postinfarction ventricular septal defect to determine optimal time for operative intervention, to identify factors responsible for failure of operative treatment, and to determine long-term survival rates. Patients were referred for operation after expectant medical management had failed or after 6 weeks electively. The operative mortality rate was 42% and ranged from 90% for those who required operation within 1 day of 11% for those underwent surgery after 1 month. In a multivariate discriminant analysis of preoperative variables, we found that inferior infarction with perforation (P less than 0.02) and preoperative multisystem failure (evidenced by abnormal mental status, P less than 0.02) were the major factors correlating with high operative risk. Early operation per se did not affect operative mortality rates. Technical problems with early operation were not a source of major morbidity and mortality. Actuarial long-term survival was good, and 88.5% of survivors were alive 5 years after surgery. Because preoperative multisystem failure is often progressive, we recommend immediate operation for all patients with postinfarction ventricular septal defect unless no deterioration is present. Moreover, because of the high risk of those patients with inferior infarction and perforation, we recommended immediate surgery for this group regardless of symptomatic status.

Emergency resuscitation using portable extracorporeal membrane oxygenation.

Manual cardiopulmonary resuscitation is currently the standard treatment for cardiac arrest patients both in and out of the hospital. Accumulated experimental and anecdotal clinical evidence suggests enhanced survival in patients with extreme circulatory decompensation who have been emergently supported with portable cardiopulmonary bypass. Long-term survival is possible even when application is delayed, but early institution of support after cardiac arrest in selected patients offers the best survival advantages. In our hospital this has been achieved by training a team of in-house personnel to emergently prepare, apply, and temporarily manage cardiopulmonary bypass until personnel with greater specialty training arrive. Machinery needed to perform emergency cardiopulmonary bypass is currently available in all hospitals with open heart surgery programs. Simple support is often therapeutic but can also serve as a bridge to definitive diagnostic and other therapeutic procedures. Commercial units are becoming more biocompatible and easier to use, making both wider application and more prolonged support likely in the future.

Prevention of distal limb ischemia during cardiopulmonary support via femoral cannulation.

The indications for prolonged cardiopulmonary support or extracorporeal membrane oxygenation are expanding. A potential serious complication of these techniques is distal limb ischemia. Techniques have been developed to provide the distal limb with blood flow. Unfortunately, specialized skills and materials are required. We describe a simple method of providing distal limb perfusion using ordinary pressure tubing and a standard cordis catheter. This technique is capable of reproducing normal superficial femoral artery blood flow.

Comparisons of methods of myocardial hypothermia for cardiac transplantation.

BACKGROUND: Myocardial hypothermia of less than 10 degrees C is an essential component of preservation of donor hearts before implantation. Here we report temperature changes and comparison of methods for maintenance of myocardial hypothermia during implantation. METHODS: Twenty patients were prospectively randomized into two equal groups. In one cohort myocardial hypothermia was maintained by the "Stanford method" of continuous lavage of the pericardium and left atrium with refrigerated saline solution. In the other a cooling jacket was used without saline lavage. Temperatures at multiple sites were measured at 30-second intervals from initiation of cardiac suturing until aortic cross-clamp removal. Comparisons were made between groups at each temperature site. RESULTS: The cooling jacket group temperatures were significantly lower at the left ventricular epicardium and endocardium than those of the Stanford method group. CONCLUSIONS: During cardiac implantation maintenance of myocardial hypothermia with a cooling jacket resulted in significantly deeper and more consistent hypothermia of the left ventricle than pericardial and left atrial lavage with refrigerated saline solution. Blood loss from aspirated saline lavage and perfusate dilution by the saline solution were eliminated.

Multiple coronary artery bypass using sequential technic.

The relief of symptoms of myocardial ischemia and its lasting effect may be related to completeness of myocardial revascularization. Multiple bypass grafting to arteries with lesser stenosis and to small arteries can be simplified by use of the sequential technic. This can be done with no added risk, but its ultimate effectiveness will have to be determined at a much later date.

The treatment of low cardiac output syndrome following cardiopulmonary bypass using delayed sternal closure.

The purpose of this study, was to ascertain whether delayed sternal closure (DSC) could eliminate the need for an intra-aortic balloon pump (IABP) or ventricular assist device (VAD) in patients with low cardiac output syndrome (LCOS) following coronary artery bypass grafting surgery (CABG). To investigate this, the records of 3014 patients undergoing CABG were retrospectively reviewed. Sixty (2.0%) patients had a relative or absolute contraindication to IABP or VAD use and required DSC for LCOS. DSC resolved 45 (75%) of these patients' LCOS, requiring an average of 1.6 +/- 0.7 days and producing a mean change in cardiac index of +1.0 +/- 0.3 L/min/m2. Fifteen (25%) of these patients did not resolve their LCOS after DSC and required either an IABP (11) or a VAD (4). Significant postoperative morbidity occurred in 22 (36.7%) patients but were not related to DSC. Only one (1.7%) sternal wound infection occurred from a total of 147 patient-days of DSC. Operative mortality was 47 per cent (28) but was not unexpected based on the number of urgent/emergent (48; 80%) and reoperative (40; 67%) procedures but does not appear to be related to the technique of DSC. DSC appears to be a simple and safe method for treating LCOS following CABG. It is effective in resolving the majority of patients' LCOS without the addition of any significant morbidity. DSC also spares these patients the added morbidity, mortality, and cost associated with circulatory assist devices.

Prolonged extracorporeal circulation for acute myocarditis.

Total circulatory support for acute reversible myocardial failure is rarely used in clinical situations outside the postoperative period following cardiac surgery. We treated an 8-year-old girl who suffered acute viral myocarditis and sustained cardiac arrest requiring cardiopulmonary bypass for resuscitation. This was accomplished with the use of the portable cardiopulmonary support system (CPS), which consists of a centrifugal pump and a membrane oxygenator. This patient was placed on CPS in Hawaii and transported after 3 days to San Diego (4200 km) for further mechanical support and possible heart transplantation. Adequate cardiac function returned and CPS was stopped after 6 days. She is alive and well, attending school two and a half years after the event. Prolonged use of CPS for acute myocardial failure outside the operating room, including long distance transportation, is effective and easily accomplished with currently and widely available equipment, and should be used in acute, reversible catastrophic heart disease.