Cardiac aneurysm complicated by E. coli abscess.

An E. coli myocardial abscess developed in the region of an old aneurysmal myocardial scar. In spite of vigorous antibiotic therapy fever and positive blood cultures persisted. A combination of In-111 WBC scanning and Tc-99m RBC gated heart imaging located the infection in the aneurysmal scar. The abscess was resected and the patient survived.

Beneficial metabolic effects of methylprednisolone sodium succinate in acute myocardial ischemia.

The metabolic and hemodynamic effects of methylprednisolone sodium succinate (40 mg/kg body weight) after acute myocardial ischemia were determined in 24 heparinized mongrel dogs. Myocardial ischemia was produced by ligation of the left anterior descending coronary artery. Catheters in the coronary sinus and the vein draining the left anterior descending coronary arterial area were used to collect blood samples from nonischemic and ischemic myocardium. Lactate, pyruvate, glucose, free fatty acids and oxygen were measured in arterial and venous blood from ischemic and nonischemic areas before and 3, 30 and 60 minutes after myocardial ischemia in animals with (Group II) and without (Group I) steroid treatment. In both Groups I and II glucose, lactate, free fatty acids, oxygen and coronary blood flow in nonischemic areas were not significantly changed, whereas glucose uptake in ischemic areas was significantly increased with myocardial ischemia and remained elevated. In Group I lactate uptake in ischemic areas became negative after coronary arterial ligation and remained so; in Group II, it increased after 30 (70%) and 60 (111%) minutes. Free fatty acid uptake in ischemic areas was reduced after myocardial ischemia in Group I, but in Group II it increased after 30 (224%) and 60 minutes (173%), and there was a concomitant increase in oxygen uptake. Pyruvate uptake in nonischemic areas decreased after 60 minutes in Group I, whereas it was reduced after 30 (68%) and 60 minutes (513%) in Group II. The changes were similar in ischemic myocardium. There were no significant changes in hemodynamic indexes. Coronary blood flow in ischemic areas decreased in Group I after myocardial ischemia and further after 30 and 60 minutes, but in Group II it increased after 30 (82%) and 60 minutes (53%). The data indicate that administration of methylprednisolone results in improved collateral blood flow into the infarcted area and a significantly improved metabolic response of ischemic myocardium. The glucocorticoid may also have a direct benefical effect on carbohydrate metabolism and cause the increased pyruvate neccesary to maintain the generation of energy-producing substrates. The results also suggest that methylprednisolone increases cell survival time and results in greater salvage of ischemic myocardium.

Tricuspid valve replacement for Ebstein's anomaly in childhood with a Starr-Edwards caged-ball prosthesis. 21-year follow-up.

A 21-year follow-up after tricuspid valve replacement (TVR) with a Starr-Edwards caged-ball prosthesis in a ten-year old boy is described. TVR is performed for Ebstein's anomaly, with strict indications in childhood. Despite the current preference for bioprostheses, good performance can be expected from the Starr-Edwards caged-ball valve.

Management of long-standing cardiocutaneous fistulas after resection of left ventricular aneurysms.

Cardiocutaneous fistulas arising from pledgets used in the closure of resected left ventricular aneurysms are rare but have serious implications. The case histories of four patients, each managed in a somewhat different manner, are presented. From this experience we recommend an aggressive approach to remove the infected pledgets once scar formation is complete and before erosion of the pledgets into the left ventricular cavity can occur.

The effect of continued cigarette smoking on the patency of synthetic vascular grafts in Leriche syndrome.

The effects of continued smoking were studied in 187 consecutive patients who underwent aorto-iliac or aorto-femoral grafting because of Leriche disease and who left the hospital with well-functioning grafts. The patients were divided into the following groups: (1) never smoked, (2) stopped smoking after the operation, (3) continued to smoke less than a pack a day and (4) continued to smoke more than a pack a day. The patency of the grafts was evaluated at regular intervals during a follow-up period ranging from 6 months to 10 years. A significant difference in the patency in the favor of the nonsmokers was found, with the "more than one pack a day" group having more than triple the occlusion rate of the nonsmokers, both absolutely and in month-patency time. We recommend that the surgeon make a most sincere effect to induce patients undergoing vascular operations for occlusive vascular diseases to give up smoking. Failure to promise to stop the smoking habit should be regarded as a relatively strong contraindication for surgery in patients not directly threatened with loss of an extremity.

Left ventricular myotomy. Physiologic approach to surgical therapy for IHSS.

Twenty patients were operated on for idiopathic hypertrophic subaortic stenosis (IHSS) between 1966 and 1980. All were in New York Heart Association functional class 3 or 4, and 17 had overt congestive failure. The mean resting gradient across the left ventricular (LV) outflow tract preoperatively was 78 mm Hg. Seventeen patients underwent transaortic LV myotomy, one had mitral valve replacement (MVR), and two patients with rheumatic mitral insufficiency (MI) and IHSS underwent myotomy and MVR. There was one operative death (5 percent). Mean follow-up was 5.8 years. Eighteen of 19 survivors were improved to class 1 or 2. One patient whose gradient and symptoms were not relieved by myotomy was improved by myectomy and MVR. The MI was abolished or reduced by myotomy in ten of 13 patients. There were six late deaths, five of which are known or assumed to be cardiac related. We concluded that LV myotomy is a safe and effective technique for surgical management of IHSS. Left ventricular myectomy, MVR, or both are indicated in selected cases.

Effect of intra-aortic balloon pumping on nutrient coronary flow in normal and ischemic myocardium.

The effects of intra-aortic balloon pumping (IABP) on myocardial flow distribution were studied in 50 dogs. Cardiac output was controlled by right heart bypass. In each dog the following parameters were measured with and without IABP during normal coronary perfusion and after regional ischemia was induced by anterior descending coronary vein flow by timed collection, and endocardial/epicardial flow ratios by a previously reported thermal washout technique. In nonischemic myocardium, IABP significantly (p less than 0.05) increased mean coronary sinus flow 11.5 percent +/- 5.8 percent (S.D.) and the mean endocardial/epicardial ratio, 17.3 percent +/- 0.28 percent. In the regionally ischemic myocardium, IABP significantly (p less than 0.05) increased mean segmental coronary vein flow 13.9 percent +/- 1.23 percent but decreased the endocardial/epicardial ratio 29.9 percent +/- 1.1 percent. We conclude that in the dog, IABP enhances subendocardial blood flow in perfused but not in ischemic myocardium. Contrary to common suppositions, the increase in collateral blood flow with IABP preferentially supplies epicardial layers in segmental ischemic zones, but may be shunted from the subendocardium.

Strut failure of the Starr-Edwards cloth-covered metallic ball prosthesis. Report of two asymptomatic cases and review of the overall experience.

Two cases of asymptomatic strut failure of an aortic Starr-Edwards cloth-covered metallic ball prosthesis are reported. Strut failure can be asymptomatic for years. Available information on the overall worldwide experience of six cases is reviewed and suggestions made for early diagnosis and treatment of this rare complication.

Coronary artery surgery without global ischemia.

A simple technique for local occlusion of the coronary artery without aortic cross-clamping during the distal anastomosis has been developed. The use of this internal coronary artery occluder, which we developed, represents another step forward in myocardial protection during coronary bypass procedures.

A comparative synchronous coronary surgery survival study.

Utilizing patient criteria published by the Veterans Administration Cooperative (VAC) Study, a cohort of 229 surgically treated patients was retrieved from the Milwaukee Cardiovascular Data Registry. These patients were all operated on by one surgeon during 1972 to 1974. Four-year survival of this group was compared with that of the medically treated cohort of 310 patients from the VAC Study. Operative mortality was included in all surgical groups. The cumulative 4-year survival of both groups revealed a 95 to 85% advantage for surgical therapy. In patients with three-vessel disease, the cumulative survival favored surgical therapy--94% compared with 80% in the medically terated cohort--and in patients with triple-vessel disease and a normal left ventricle, surgical therapy again showed better results: 100% compared with 88%. Patients with two-vessel disease and a normal left ventricle who underwent surgical intervention had slightly better 4-year survival than those who had medical treatment--100% versus 95%--and those with two-vessel disease and an abnormal left ventricle had a 93% survival after surgical treatment compared with 84% for those with medical treatment. For patients with single-vessel disease, there was no difference in survival between the surgical and medical cohorts.

Sutureless fixation of long aortocoronary saphenous vein grafts with oxidized regenerated cellulose.

A technique of sutureless epicardial fixation of long aortocoronary saphenous vein grafts using oxidized regenerated cellulose is illustrated. Sutureless fixation has been previously performed with fibrin glue. Possible advantages of using oxidized regenerated cellulose instead of fibrin glue are discussed.

Life-threatening chylothorax after left internal mammary artery dissection: therapeutic considerations.

Persistent chylothorax developed in a 53-year-old man after left internal mammary artery (LIMA) takedown and required surgical intervention. After an unsuccessful supraclavicular approach, left-sided standard thoracotomy showed thick adhesions around the LIMA takeoff with a diffuse oozing rather than an identifiable discrete leak. A possible leaking point was stitched, the area was sealed with fibrin adhesive, and complete remission ensued. Operation for chylothorax after LIMA takedown is challenging. A left-sided standard thoracotomy with minimal dissection and use of fibrin adhesive rather than blind stitching are recommended.

Late evaluation of patients undergoing valve replacement with the Björk-Shiley prosthesis.

This study analyzes 484 patients who survived mitral, aortic, or mitral and aortic valve replacement using the Björk-Shiley prosthesis from January, 1970, through December 31, 1974. Long-term follow-up of 1 1/2 to 6 1/2 years (mean, 3.67 yr) was done on 435 patients (98.2%). Eighty to 85% of the patients have improved noticeably. Thromboembolic problems occurred in 6.9%, representing 1.5 emboli per 1,000 patient-months. Anticoagulant bleeding problems occurred in 6.4% of the patients; late mortality was 15%. Actuarial survival curves showed patients at risk to 6 years having a 79% chance of survival. The same analysis according to preoperative New York Heart Association Functional Classification showed a striking reduction in survival in class IV patients. The Björk-Shiley prosthesis is a good choice for valve replacement today. Earlier diagnosis and treatment are needed to obtain better long-term survival.

Ten-year follow-up in aortic valve replacement using the Björk-Shiley prosthesis.

An in-depth statistical analysis of early and late results of aortic valve replacement using the Björk-Shiley tilting-disc prosthesis is presented. Our experience with this prosthesis indicates that replacement carries a low surgical risk, a low incidence of complications (embolization, infection, or hemorrhage due to long-term use of anticoagulants), and good long-term survival. Coexisting coronary artery disease increases surgical mortality significantly, and simultaneous, complete revascularization is essential. Patients undergoing isolated aortic valve replacement did significantly better than those requiring other simultaneous procedures or those who had had previous operations. Earlier operation is imperative since progress of aortic valve disease is unpredictable by duration of symptoms, and patients in New York Heart Association Functional Class II have a low surgical risk and a greatly increased survival. It would appear from this study that additional criteria, such as increasing ventricular dilatation and hypertrophy determined by echocardiographic studies and gated nuclear studies showing deterioration of ejection fraction on exercise, should be used to help determine time of surgical intervention rather than symptomatology alone.

Prognostic considerations in the management of left ventricular aneurysms.

This report summarizes a four-year experience with 60 patients who had left ventricular aneurysm (LVA) resection and bypass of all significantly diseased coronary arteries, with an operative and late mortality of 3.3 and 8.3%, respectively. Their cardiac catheterizations were reviewed, and the only values that seemed to reflect prognosis were preoperative cardiac index and the presence of absence of septal motion. The lower the cardiac index, the less likely the patient was to do well postoperatively. There were now survivors who had lacked septal motion by left anterior oblique ventriculogram. Patients without septal motion are therefore no longer considered surgical candidates. If septal motion is present, resection of LVA carries no more risk than myocardial revascularization without LVA.

Survival and "event-free" analysis of 785 patients with Björk-Shiley spherical-disc valves at 10 to 16 years.

Seven hundred eighty-five patients underwent Björk-Shiley spherical-disc valve replacement from 1970 to 1976. There were 268 mitral valve replacements (MVR), 227 aortic valve replacements (AVR), 65 double-valve replacements, and 225 "combined" procedures. A 97.2% follow-up (mean, 12 years) was achieved. With an operative mortality of 4.1% for MVR, 8.4% for AVR, 15.4% for double-valve replacement, and 12.4% for combined procedures, the 12-year survival was most closely related to age at valve replacement: age less than 50 years, 70%; age 50 through 59 years, 52%; and age 60 years or more, 38%. Twenty-four patients (3.1%) (6 who had MVR, 5 who had AVR, 1 who had double-valve replacement, and 12 who had combined procedures) had a thrombosed valve 1 to 134 months postoperatively; this is equal to 0.36 thrombosed valve per 100 patient-years. One hundred eighteen embolic episodes occurred in 94 (13%) of the operative survivors or 1.8 emboli per 100 patient-years. There were major bleeding complications in 0.5% of patients and minor bleeding complications, in 4.0%. Endocarditis appeared in 30 patients (4.2%) or 0.4 episode per 100 patient-years and paravalvular leaks, in 20 patients (2.8%). The event-free survival by age group and valve site at 5, 10, and 12 years is presented. Events included death, thrombosed valves, strokes, bleeding, emboli, paravalvular leaks, and endocarditis. There were 5.3 events per 100 patient-years excluding operative deaths.

Results of intraaortic balloon pumping after cardiac surgery: experience with the Percor balloon catheter.

One hundred thirty-eight patients undergoing an open-heart procedure required an intraaortic balloon pump (IAPB) postoperatively. In Group I (N = 45), the AVCO femoral conduit surgical technique was used; in Group II (N = 93), the Percor balloon was inserted either in the operating room after groin cutdown (open insertion) or percutaneously in the intensive care unit (percutaneous insertion). IABP usage increased in Group II (3% versus 1.6%; p less than 0.001). Immediate mortality was 40% (55/138). Use of the Percor balloon in Group II resulted in lower immediate mortality (32/93 or 34% versus 23/45 or 51%; p less than 0.06). Delayed mortality from multiorgan failure was 11.6% (16/138). Immediate percutaneous insertion at the bedside rather than a return to the operating room for open insertion yielded lower mortality (2/8 or 25% versus 6/7 or 86%; p less than 0.05). Open insertion of the Percor balloon decreases the failure rate of insertion compared with both the AVCO femoral conduit technique (7/85 or 8.2% versus 5/45 or 11%) and percutaneous insertion. It has more complications than the AVCO femoral conduit technique (7/85 or 8.2% versus 2/45 or 4.4%) and less than percutaneous insertion.

Improved early results after aortic valve replacement: analysis by surgical time frame.

Primary aortic valve replacement was performed in 430 patients. It was an isolated procedure in 339 and was combined with coronary artery bypass grafting in 91. Of these patients, 282 underwent operation from 1970 through 1976 (time frame 1) and 148 from 1980 through 1985 (time frame 2). They were divided into subgroups by age, New York Heart Association functional class, combined coronary artery bypass graft, and valvular lesion. Overall hospital mortality was 7.7% (time frame 1 = 10.6% versus time frame 2 = 2.0%; p less than 0.01). Overall, functional class III or IV was the strongest predictor of hospital mortality (p less than 0.001). Association of coronary artery bypass graft was the next strongest predictor of hospital mortality (p less than 0.01), and it retained its predictive value in time frame 2. Overall, hospital mortality was higher in patients older than 55 years (10.5% versus 3.5%; p less than 0.05). There were no hospital deaths in patients younger than 55 years in time frame 2. Type of valvular lesion was not a predictor of hospital mortality. Hospital mortality in patients receiving cardioplegia was 2%. Cardioplegia use has lessened the effect of age and functional class as predictors of hospital mortality after primary aortic valve replacement. Earlier operation in time frame 2 played a substantial role in the overall improvement of early results.

Long-range observations with external aortic grafts.

The late results of aortic aneurysms treated by external grafting are presented. This procedure consists of completely dissecting the involved aortic segment and suturing it in a well-fitted tubular Dacron prosthesis. The operation was carried out under the following circumstances: (a) Small fusiform aneurysm of the abdominal aorta. (b) Small and medium-sized aneurysms of the thoracic aorta. (c) Aneurysms unfavorably located in the very old and very debilitated. (d) Aneurysms involving the origin of the renal arteries. (e) Aneurysmatic dilatation of the aortic arch. Sixty-two patients were operated upon with this method with the follow-up period ranging from three months to seven years. There were no deaths during this period which could be directly related to either the aneurysm or the procedure itself.

Selection of patients for coronary bypass surgery.

We have tried to present a rational approach to selection of patients for coronary bypass surgery. An evaluation of both the anatomic and the clinical status of a patient in whom coronary arteriography has been performed, along with consideration of known results of medical and surgical forms of treatment of coronary artery disease in large series, determines which therapy is preferable. In all instances, the goal of treatment is threefold: relief of pain, preservation of myocardium and prolongation of life. In properly selected patients, pain can be relieved by surgery 90% of the time. Preservation of myocardium is a reality in some groups of patients treated surgically. Current data indicate that prolongation of life by coronary bypass surgery occurs in patients with left main coronary or triple-vessel disease, and as more data are collected, other subgroups may be included.