Inadvertent retrieval of a broken PTCA catheter from the aorta during off-pump coronary bypass.

To cut costs, many centres around the world utilise previously used, re-sterilized balloon catheters to perform coronary angioplasty. The fracture and lodging of an angioplasty device within the coronary arteries is a rare but increasingly noted complication. In this article, we report on the inadvertent retrieval of a coronary angioplasty catheter during off-pump coronary bypass. The accidental removal of the catheter, which extended to the descending aorta, has obviously been life saving. This experience has shown that a high degree of caution is required when planning an operation for the retrieval of PTCA hardware.

Off-pump coronary bypass for advanced left ventricular dysfunction.

BACKGROUND: In this study the results of off-pump bypass in patients with advanced left ventricular dysfunction (LVD) and without bypassable circumflex disease were analysed retrospectively. METHODS: Fifty-five patients with advanced LVD underwent off-pump coronary bypass. Their ages ranged from 39 to 82 years (mean 62.3 +/- 8.4). Forty-two of the patients (76.3%) were in NYHA class III or IV. Mean left ventricular ejection fraction (LVEF) was 23.8 +/- 5.1%. Pre- and intra-operative variables, and postoperative complications and mortality of the patients were analysed. Mid-term follow-up was done by telephone either with the referring cardiologist or the patients. RESULTS: The mean number of coronary artery bypass grafts (CABG) per patient was 2.22 +/- 0.63. Eight coronary endarterectomies were achieved; early mortality was 3.6%. Pre-operative myocardial infarction (MI) occurred in one patient (1.8%). Two patients (3.6%) were supported with an intra-aortic balloon pump (IABP) and 10 (18.1%) needed inotropic support. Mean postoperative blood loss was 425 +/- 50 cm3. A significant improvement in ejection fraction was observed in the postoperative course. Mean intensive care unit stay was 2.1 +/- 1.1 days and mean hospital stay was 7.2 +/- 1.3 days. The mean follow-up period was 21.8 +/- 6.2 months and mid-term survival was 2.4%. Freedom from cardiac events requiring hospital admission was 89.7%. Most of the patients enjoyed symptomatic relief, however 16 patients (32.6% of survivors) remained in NYHA class III. CONCLUSION: These results support the effectiveness of off-pump coronary bypass with good early and mid-term results in patients with ischaemic cardiomyopathy and without bypassable circumflex lesion.

The inhibition of pro-inflammatory cytokines with pentoxifylline in the cardiopulmunary bypass lung.

In addition to preventing tissue energy loss during cardiopulmonary bypass, pentoxifylline (Ptx) prevents the production of pro-inflammatory cytokines as well. The aim of this study was to investigate whether Ptx decreases the inflammatory effects of cardiopulmonary bypass on the lungs during open-heart surgery. The patients in the study group (n = 15) who were going through an open-heart surgery had 500 mg l(-1) of Ptx added to their prime solution, whereas the patients in the control group (n = 10) only received prime solution. Pre-pump and post-pump blood samples were obtained from both groups and assayed for interleukin-6 (IL-6), interleukin-8 (IL-8) and tumour necrosis factor alpha (TNFalpha). Lung tissue samples that were obtained after the pump were examined with light microscopy and stained for tissueTNFalpha. Non-parametric Wilcoxon test was utilized for statistical evaluation. In the post-pump period, the difference in the IL-6, IL-8 and TNFalpha levels of the two groups was found to be statistically significant (P<0.005). The tissue samples from the control group had significant staining with TNFalpha. We think that Ptx has important protective effects on the lungs during cardiopulmonary bypass.

Fungal left ventricular assist device endocarditis.

BACKGROUND: Infection remains as the most serious complication and represents a significant threat to patients during long-term mechanical circulatory support. Fungal infection is a particularly worrisome complication and left ventricular assist device (LVAD) endocarditis does pose a serious threat. METHODS: One hundred and sixty-five patients underwent TCI Heartmate LVAD implantation between July 1991 and December 1999 at our institution. Detailed medical records were kept prospectively for all patients, and a variety of infection-related endpoints were analyzed on patients with fungal LVAD endocarditis. RESULTS: Thirty-seven patients (22%) developed fungal infections during LVAD support. Five (3%) of those met our criteria for the diagnosis of fungal LVAD endocarditis. Microbial portals of entry were identifiable in all cases. Infections were managed successfully in 4 patients (80%). CONCLUSIONS: The successful management of fungal LVAD endocarditis currently requires early recognition of potentially nonspecific signs and symptoms, and timely institution of antifungal therapy. In some cases with device-specific manifestations of LVAD endocarditis, device removal and replacement is necessary. In patients with clinical manifestations of sepsis and fungal driveline site or pocket infections without positive blood culture, urgent transplantation may be the appropriate management. In the setting of shortage in the donor supply, device removal and replacement is necessary.

Nitric oxide usage after posttraumatic pneumonectomy.

Pneumonectomy is rarely required in the surgical management of thoracic traumatic injuries with high mortality rates. Right heart failure due to elevated pulmonary artery pressure and the adult respiratory distress syndrome have been leading causes of mortality reported after posttraumatic pneumonectomy. The beneficial effect of inhaled nitric oxide has been shown in pulmonary hypertension and in adult respiratory distress syndrome. We report the use of inhaled nitric oxide in the perioperative management of a patient undergoing emergent pneumonectomy.

Considerations in biventricular repair after the Norwood procedure.

OBJECTIVE: The Norwood procedure can be applicable as a first stage palliation in children who can eventually undergo a biventricular repair. Although usual management of these patients is a primary neonatal repair, in selected patients staged approach with a Norwood procedure in the neonatal period followed by a Rastelli procedure in the infancy for conversion to two-ventricle physiology has been used alternatively. METHODS: We report our experiences on two infants who underwent a previous palliation with the Norwood procedure for lesions other than hypoplastic left heart syndrome and converted to two-ventricle physiology by the use of a Rastelli-type procedure. This report examines considerations in biventricular repair after the Norwood procedure especially need for ventricular septal defect enlargement and approach to placement of the right ventricle to pulmonary artery conduit. RESULTS: Both of the infants who underwent staged approach with an initial Norwood procedure for lesions other than hypoplastic left heart syndrome survived the operations and were clinically well at mid-term follow-up. CONCLUSION: In selected patients, the staged approach is an alternative in management of malformations other than hypoplastic left heart syndrome which share the important physiologic features of aortic outlet obstruction and ductal dependency of systemic circulation. We recommend routine enlargement of ventricular septal defect and proper positioning of the conduit at the time of subsequent biventricular repair.

Atrial fibrillation after coronary artery bypass surgery: predictors and the role of MgSO4 replacement.

BACKGROUND: Supraventricular arrhythmias continue to complicate the postoperative course of patients undergoing myocardial revascularization. The aim of the study was to identify factors associated with atrial fibrillation (AF) and to determine the efficacy of postoperative magnesium sulphate (MgSO4) replacement on the incidence of AF after coronary artery bypass grafting (CABG) operation. METHODS: Fifty patients undergoing CABG were studied prospectively. Consenting patients with good left ventricular function and without any documented arrhythmias were randomly divided into two groups of 25 patients each in a double-blind fashion. The clinical characteristics of both groups were similar. In the study group, 200 mEq MgSO4 was given for the first 5 postoperative days, in the control group, placebo was given instead of MgSO4. RESULTS: Five (20%) patients in the control group and one (4%) patient in the MgSO4 group experienced AF. There was no significant relationship between the development of AF and the following variables: age; sex; diabetes mellitus; hypertension; previous myocardial infarction; smoking; extension of coronary artery disease; aortic cross-clamp time; number of grafts; cardiopulmonary bypass time; postoperative pericarditis; and anemia. CONCLUSION: The use of MgSO4 in early postoperative period is effective in reducing the incidence of AF after CABG in patients with good ventricular function.