Surgical treatment of postinfarction left ventricular pseudoaneurysm.

BACKGROUND: Left ventricular pseudoaneurysm from myocardial infarction is rare and is associated with a high risk of rapid enlargement and rupture. The purposes of this study were to describe its clinical presentation, assess the accuracy of diagnostic imaging modalities, and determine operative and late surgical results. METHODS: From January 1986 through December 2001, 30 patients aged 50 to 85 years (mean, 68; 70% male) underwent left ventricular pseudoaneurysm repair. Two surgical approaches were used: primary repair (n = 5, 17%) and patch closure (n = 25, 83%). Twenty-one patients (70%) had concomitant procedures, including coronary revascularization (n = 17, 57%) and mitral valve surgery (n = 9, 30%); 8 patients (29%) underwent emergent surgery. Clinical presentation, preoperative imaging data, and surgical outcomes were abstracted from medical records or obtained by patient follow-up. RESULTS: The most common clinical presentations were heart failure (n = 22, 73%) and angina (n = 11, 41%). Pseudoaneurysm was rarely suspected at clinical presentation. Contrast ventriculography was diagnostic in 54% of patients in whom it was performed, as opposed to 97% for two-dimensional echocardiography (p = 0.2). Postoperative intra-aortic balloon pump was required in 7 patients (23%). Hospital mortality was 20%, and late survival was 73%, 59%, and 45% at 1, 5, and 8 years, respectively. CONCLUSIONS: Left ventricular pseudoaneurysm should be suspected in postinfarction patients with unexplained heart failure. Echocardiography is usually diagnostic and is superior to ventriculography. The surgical mortality rate is elevated in this complex patient population. Long-term survival is also poor, mainly because of underlying ischemic cardiomyopathy.

Does use of a right internal thoracic artery increase deep wound infection and risk after previous use of a left internal thoracic artery?

OBJECTIVE: To determine whether adding right internal thoracic artery to previous left internal thoracic artery bypass at reoperation increases deep sternal wound infection and hospital mortality, particularly in diabetic patients. METHODS: Reoperations (n = 2875; 2381 men) in patients with previous left internal thoracic artery bypass were performed between January 1990 and January 2003; 1939 (67%) had no repeat internal thoracic artery grafting, 923 (32%) received an additional right internal thoracic artery graft, and 13 (0.5%) had bilateral internal thoracic artery grafting with reuse of the left internal thoracic artery. Of the patients, 352 (12%) were insulin-treated and 590 (21%) non-insulin-treated diabetics. Multivariable logistic regression analysis was used to identify preoperative variables associated with right versus non-right internal thoracic artery use in diabetics and nondiabetics and to formulate propensity models. Propensity scores were used for matching and adjusted multivariable analyses of deep wound infection and hospital mortality. RESULTS: Deep wound infection occurred in 3.0% (7/230) of diabetics receiving right internal thoracic artery grafts, 2.2% (5/230) of propensity-matched diabetics receiving non-right internal thoracic artery grafts (P = .6), in 1.1% (6/538) of nondiabetics receiving right internal thoracic artery grafts, and in 1.0% (5/538) of matched non-diabetic patients receiving non-right internal thoracic artery grafts (P = .8). Corresponding hospital mortality in these matched groups was 1.7% (4/230) versus 6.1% (14/230) for diabetics (P = .02) and 2.6% (14/538) versus 3.5% (19/538) for nondiabetics (P = .4). Risk factors for deep wound infection included higher weight (P = .0003), higher New York Heart Association functional class (P = .03), and less severe left anterior descending disease (P = .03). Risk factors for death were (P < .02) emergency operation, mitral valve replacement, and greater number of saphenous vein grafts. CONCLUSIONS: Use of the right internal thoracic artery for reoperations does not increase the risk of deep wound infections in diabetics or nondiabetics and does not increase mortality.

Surgical treatment of pseudoaneurysm of the thoracic aorta.

OBJECTIVES: To examine the clinical profiles, operative outcomes, and late results of patients with pseudoaneurysm of the thoracic aorta. METHODS: From 1990 to 2002, 60 patients underwent repair of aortic pseudoaneurysm: ascending aorta in 70%, ascending aorta and arch in 15%, descending aorta in 10%, and arch alone in 5%. Mean age was 53 +/- 15 years, and 70% were men. Of these, 50 (83%) had undergone previous cardiac surgery, including 22 (37%) composite valve graft operations. The preferred cannulation site was femoral-femoral (n = 27, 45%), with deep hypothermic circulatory arrest in 62% and retrograde cerebral perfusion in 33%; more recently, however, axillary cannulation has been preferred. RESULTS: Principal etiologies were graft infection in ascending aorta pseudoaneurysm and trauma in descending aorta pseudoaneurysm. Fifteen patients (25%) presented with chest pain, 13 (22%) with heart failure, and 20% with moderate or severe aortic regurgitation. The pseudoaneurysm was resected and the aorta replaced (n = 45, 75%) or repaired (n = 15, 25%) using various methods. Hospital mortality was 6.7% (n = 4). Reexploration for bleeding was required in 8.3%, and 3.3% had postoperative stroke. At 30 days, 5 years, and 10 years, survival was 94%, 74%, and 60% and freedom from reoperation was 95%, 77%, and 67%, respectively. CONCLUSIONS: Most patients with aortic pseudoaneurysm require ascending aorta and/or arch replacement, which can be accomplished with low operative mortality and morbidity. Long-term survival and freedom from reoperation in these young patients parallel those expected for complex cardiac and aortic disease.

Surgery for permanent atrial fibrillation: impact of patient factors and lesion set.

BACKGROUND: Whether a complete Cox-maze procedure is needed to ablate permanent atrial fibrillation in patients undergoing concomitant cardiac surgery is unknown. Our objective was to assess the effectiveness of different lesion sets in such patients. METHODS: From November 1991 to January 2004, 575 patients underwent surgical treatment of permanent atrial fibrillation (duration > 6 months); mitral valve disease was the primary indication for surgery in 74%. Procedures included pulmonary vein isolation alone (n = 68, 12%), pulmonary vein isolation with left atrial connecting lesions (n = 265, 46%), and Cox-maze (n = 242, 42%). Rhythm documented on 5,120 postoperative electrocardiograms was used to estimate time-related prevalence of, and risk factors for, atrial fibrillation. RESULTS: Prevalence of postoperative atrial fibrillation peaked at 46% two weeks after operation, declining to 24% at one year. Patient-related risk factors for increased prevalence included older age (p < 0.0001), larger left atrium (p < 0.0001), and longer duration of preoperative atrial fibrillation (p = 0.0008). The Cox-maze procedure and lesion sets resembling it created with alternative energy sources had a similarly low prevalence of late postoperative atrial fibrillation; in contrast, pulmonary vein isolation and lesion sets that did not include a lesion to the mitral anulus were less effective. CONCLUSIONS: This study suggests that in cardiac surgical patients with permanent atrial fibrillation the left atrial lesion set should include wide pulmonary vein isolation, at least one connection between right and left pulmonary veins, and a connection to the mitral anulus. Availability of alternative energy sources to create lesions sets has virtually eliminated the need for the cut-and-sew Cox-maze procedure.

Extended use of extracorporeal membrane oxygenation after lung transplantation.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) for severe graft failure after lung transplantation is accepted immediately postoperatively; extending its use is controversial. We evaluated our post-lung transplant ECMO experience, which included extended indication, to (1) determine its prevalence, risk factors, indications, and timing, (2) compare complications and outcomes of these patients with those not requiring it, and (3) identify risk factors, including indications, for mortality. METHODS: From February 1990 to October 2005, 474 patients underwent lung transplantation; postoperative ECMO support was instituted for severe graft failure 23 times in 22 patients (4.0%). Indications for ECMO and its timing were obtained by reviewing medical records and survival by systematic follow-up. RESULTS: No factor evaluated predicted severe graft failure leading to ECMO. The most common indication for ECMO was early graft failure (13 patients); however, it was also used for pneumonia or sepsis (6) and acute rejection (4). ECMO was initiated at a median arterial oxygen tension/inspired oxygen fraction of 59 at a median of 2 days postoperatively and was maintained for a median of 4 days. The most common complications were renal failure (57%) and bleeding (43%). ECMO was effective in salvaging patients with rejection and early graft failure (survival at 1, 3, 6, and 12 months: 62%, 54%, 49%, and 41%), but ineffective for pneumonia or sepsis (survival at these intervals: 9%, 4%, 4%, and 3%). CONCLUSIONS: ECMO can be extended beyond early severe graft failure to acute rejection and can be considered after the immediate postoperative period. Survival after ECMO in patients with pneumonia or sepsis is poor.