Left ventricular free wall rupture as the presenting manifestation of acute myocardial infarction in diabetic patients.

We present 5 diabetic patients with acute myocardial infarction in whom left ventricular free wall rupture was the presenting manifestation. Echocardiography may be indicated in diabetic patients with acute myocardial infarction and in shock, prior to thrombolysis.

Management of the left atrioventricular valve in the repair of complete atrioventricular septal defects.

Left atrioventricular valve regurgitation in atrioventricular canal defects is usually due to malalignment of the edges of the cleft or to annular dilatation. Intraoperative assessment and correction of left atrioventricular valve incompetence is critical for successful outcome in the surgical management of complete atrioventricular canal defects. Although some have elected not to suture the cleft in the setting of minimal incompetence, we have found that this often results in significant left atrioventricular valve insufficiency, necessitating reoperation. From January 1982 through December 1990, 105 patients with complete atrioventricular canal underwent definitive repair. Repair was performed with a single pericardial patch technique in 86 patients (82%). Intraoperative assessment of left atrioventricular valve competence was performed in all cases. Ninety-six patients (91%) required suturing of the cleft and 63 (60%) required annuloplasty to establish satisfactory competence of the left atrioventricular valve. The overall early mortality rate was 10.5% (11/105 patients). From 1986 to 1990, the early mortality rate decreased to 7.7% (6/78 patients). In a mean follow-up of 39 months (range 1 to 106 months), late survival was 96% (90/94 operative or early survivors). Reoperation was performed on eleven (11.5%) patients; six (6.3%) for failure of the atrioventricular valve repair, three for patch dehiscence, and two for residual ventricular septal defects. These data demonstrate that routine approximation of the cleft and aggressive use of left atrioventricular valve annuloplasty is safe and results in an excellent outcome with a low incidence of reoperation for failure of left atrioventricular valve repair.

The inferior epigastric arteries as coronary bypass conduits. Size, preoperative duplex scan assessment of suitability, and early clinical experience.

We are currently evaluating the inferior epigastric artery as an alternative arterial conduit for coronary bypass grafting. Fifty-seven inferior epigastric arteries were harvested from 47 adults. There were no differences in size between the right and left inferior epigastric arteries. Diameter was 2.5 to 3.5 mm proximally and 2 to 3 mm distally. Usable length was 6 to 16 cm (mean 11.2 +/- 0.25 cm). Grade I/IV atherosclerosis was found in one patient (2.1%). Duplex scanning was used for preoperative evaluation of the inferior epigastric arteries in 51 patients. In 21 patients the arteries were not harvested, in part because of duplex scan findings of small caliber or early bifurcation. In 30 patients the duplex findings could be compared with the surgical findings. The average length at operation was twice the length detected on duplex scan (11.2 cm versus 5.8 cm, p less than 0.001). There was a good correlation between diameter on duplex scan and that measured at operation (2.56 +/- 0.05 versus 2.62 +/- 0.07, p = not significant). Between December 1989 and May 1991, 38 patients (29 to 74 years, mean 56 years) received 42 inferior epigastric artery grafts. Proximal anastomoses were to the aorta in 17, to the vein graft hood in 20, or onto an internal mammary artery graft in 5. Distal anastomoses were to the left anterior descending artery in 2, the diagonal branch in 27, the marginal branch in 9, or the right coronary artery in 4. There were no early deaths. Complications included perioperative myocardial infarction in 1, deep sternal wound infection in 2, superficial infection at the harvest site of the inferior epigastric artery in 5, and reexploration for bleeding in 2. Because of its size and the low incidence of atherosclerosis, the inferior epigastric artery may evolve as an alternative arterial conduit for coronary bypass. Duplex scanning is a valuable noninvasive tool for preoperative evaluation of the artery's suitability. Long-term studies of patency of the inferior epigastric artery as a coronary bypass conduit are needed.

Pericardial meshing: an effective method for prevention of pericardial adhesions and epicardial reaction after cardiac operations.

Cardiac reoperations, particularly for coronary revascularization, are becoming more frequent and carry increased risk of damage to the heart during resternotomy. We experimentally evaluated a pericardial meshing technique to facilitate primary pericardial closure. In 18 mongrel dogs, an 8 by 5 cm pericardial flap was fashioned through a left thoracotomy. A standardized procedure for induction of pericardial adhesions was carried out in all animals. Animals were divided into three groups of six animals each: Group I (control)--the pericardial flap was primarily resutured; Group II--the flap was meshed and then resutured; and Group III--the flap was replaced by a pericardial substitute. Animals were put to death 8 weeks postoperatively and the pericardial space was examined for adhesions and epicardial reaction. The extent of adhesions and epicardial reaction was graded as: 0--none; 1--minimal; 2--moderate; and 3--severe. Both in Group I and Group III severe pericardial adhesions (grade 2-3) and epicardial reactions (grade 2-3) were formed, which obscured the underlying coronary anatomy. In Group II pericardial adhesions and epicardial reactions were none to minimal (grade 0-1) and the underlying coronary anatomy was not obscured. The meshed pericardium was completely regenerated by normal pericardium within several weeks. This study demonstrates that pericardial meshing facilitates primary tension-free pericardial closure. Free drainage of intrapericardial blood is achieved. A complete anatomic layer between heart and sternum is restored. Pericardial meshing is superior to the pericardial substitutes examined, as adhesions and epicardial reactions are significantly reduced, and the coronary anatomy is readily identifiable.

Dacron mesh wrapping to support the aneurysmally dilated or friable ascending aorta.

A technique of supporting the aneurysmally dilated or friable ascending aorta using a fine Dacron mesh is described. In patients with aneurysmal dilatation of the ascending aorta, longitudinal resection of a portion of the aneurysm combined with wrapping can avoid replacement with a synthetic graft. The Dacron mesh, because of its transparency and ability to stretch, allows a more accurate fit over the aorta, avoids hematoma formation, provides visualization of suture lines after wrapping, and facilitates proximal vein graft anastomoses for combined aortocoronary bypass.

Use of a pericardial patch to bridge the conduction tissue during tricuspid valve replacement.

Tricuspid valve replacement carries a risk of causing complete heart block. To reduce this risk, a technique was developed to bridge the conduction system during prosthetic valve insertion in the tricuspid position. This technique, in which a pericardial patch is used to bridge the triangle of Koch, was performed successfully in 4 patients who underwent tricuspid valve replacement for Ebstein's anomaly of the tricuspid valve.

Open heart operation after pneumonectomy.

A coronary artery bypass operation was performed successfully on a 70-year-old patient who had undergone left pneumonectomy 40 years earlier. This case, together with a search of the literature and a mail survey among 118 cardiothoracic surgeons worldwide, yielded data on 27 such patients for review. Two patients died perioperatively. Three patients had pneumothorax, and 1 patient had recurrent pleural effusion. Difficulty in exposing the circumflex marginal branches was reported in 2 patients after left pneumonectomy. We conclude that with attention to the specific features of the preoperative, intraoperative, and postoperative management, open heart procedures can be performed on patients after pneumonectomy with acceptable operative mortality and morbidity.

Intraaortic balloon entrapment: a complication of balloon perforation.

A patient in whom perforation of a percutaneously inserted intraaortic balloon resulted in a clot formation inside the balloon is described. The balloon could not be withdrawn percutaneously and was lodged in the femoral artery. It was removed surgically, and the artery was repaired.

Repair of truncus arteriosus in infancy.

Improvements in myocardial protection, surgical technique, and postoperative care have decreased operative mortality for neonatal repair of truncus arteriosus. Primary repair of truncus arteriosus in infancy without prior pulmonary artery banding is currently the preferred approach. During the period from 1982 to December 1990, 32 patients under the age of 12 months underwent surgical correction of truncus arteriosus at UCLA. The average age was 3.5 months (range, 12 days to 12 months). Three patients had interrupted aortic arch. Early mortality for the entire group was 15.6% (5/32); for those older than 1 month early mortality was 7% (2/28). In the past 4 years, early mortality has decreased to 8.3% (2/24); both of these patients had interrupted aortic arch. Excluding patients with interrupted aortic arch, there were no early deaths in the last 22 patients (1986 to 1990). Late mortality overall was 7.4% (2/27). In a mean follow-up of 73 months (range, 40 to 110 months), 71% (5/7) of the survivors with Dacron porcine-valved conduits required conduit replacement secondary to obstruction. In a mean follow-up of 36 months (range, 1 to 89 months), only 14% (3/21) of the patients with homografts required replacement secondary to obstruction.

Preoperative duplex scan assessment of the inferior epigastric artery as a coronary bypass conduit.

The inferior epigastric arteries are currently being evaluated as alternative autologous arterial conduits for coronary artery bypass operations. The inferior epigastric arteries are variable in diameter and length and require harvesting through separate abdominal incisions. There is a need, therefore, for a method to preoperatively assess the diameter and length of the inferior epigastric arteries to determine their suitability as a coronary artery bypass graft. We have found that the duplex scan is a valuable noninvasive preoperative imaging modality to evaluate the inferior epigastric arteries.

Partial biventricular repair for double-outlet right ventricle with left ventricular hypoplasia.

The presence of left ventricular hypoplasia in double-outlet right ventricle may increase the risk of biventricular repair and Fontan procedures. The hypoplastic left ventricle of an 11-year-old girl with complex double-outlet right ventricle was successfully incorporated in a modified biventricular repair by Dacron patch closure of the ventricular septal defect, diversion of venous return of the inferior vena cava to the mitral valve with an intraatrial baffle, insertion of a left ventricular apex to pulmonary artery valved aortic homograft, and diversion of residual systemic venous return directly to the lungs with a bidirectional superior vena cava to pulmonary artery shunt. Postoperatively, the systemic venous atrial pressure was 6 mm Hg and the pulmonary artery pressure was 14 mm Hg. This method is proposed as a partial biventricular repair hemodynamically superior to the Fontan procedure, although aortic homograft revision may be required in the future.

Pericardial meshing: a new technique to facilitate primary tension-free pericardial closure.

A method is described to facilitate pericardial approximation at the conclusion of open-heart surgical procedures. Before sternal closure, the anterior pericardium is meshed by multiple longitudinal incisions until tension-free closure is possible. The technique was developed by animal experimentation and is now being performed in patients. It has proven to be simple, safe, and effective.

Partial Fontan: advantages of an adjustable interatrial communication.

Systemic venous hypertension after the Fontan procedure is a major cause of mortality and morbidity, accounting for 11 of 16 deaths in our series of 228 Fontan procedures. A partial Fontan with a residual atrial septal defect (ASD) would allow controlled right-to-left shunting to reduce venous pressure and improve cardiac output while maintaining a reduced but acceptable arterial oxygen saturation. This allows complete or graded closure of the ASD after the discontinuation of cardiopulmonary bypass in the operating room or at any time in the postoperative period by exposing the snare under local anesthesia. From 1987 to 1990, 36 patients undergoing the modified Fontan procedure had placement of an adjustable interatrial communication. Indications for placement of an adjustable ASD included increased pulmonary artery pressures, increased pulmonary vascular resistance, reactive airway disease, previously increased or unknown pulmonary vascular resistance, small pulmonary arteries, and borderline ventricular function. Fourteen patients had the adjustable ASD closed at the time of operation, 8 patients underwent narrowing, and 12 underwent closure of the ASD in the postoperative period. Eight patients were discharged with the ASD partially open, and 2 patients underwent delayed closure. The partial Fontan with an adjustable ASD may increase the safety of the Fontan procedure for high-risk groups such as those with increased pulmonary vascular resistance, pulmonary hypertension, and impaired left ventricular function and for infants, who tolerate venous hypertension poorly. The ability to adjust the ASD in stages depending on the hemodynamic response increases flexibility and safety.

Prevention of urethral strictures following coronary artery bypass graft surgery.

A total of 62 patients undergoing coronary artery bypass graft surgery were randomized into three groups using one of three methods for bladder drainage: 12F Foley catheter introduced after anesthesia prior to surgery (21 patients); 12F Foley catheter introduced after termination of cardiopulmonary bypass period (17 patients); or a suprapubic catheter, introduced after termination of the bypass period (24 patients). Later we also studied 39 consecutive patients undergoing coronary artery bypass graft surgery with a 12F Foley catheter introduced after anesthesia to assess the risk of urethral stricture in a larger group of patients. The patients' records were reviewed and a postal questionnaire was sent to all patients six months after surgery. The response rate was 84 percent, with 36 percent having complaints about micturition; of these 79 percent were evaluated by cystourethrography, and 2 cases of urethral stricture were found. The incidence of major postoperative complications was low, with no differences in rate among the various groups. Our results indicate that the use of small caliber Foley catheters is associated with a low incidence of urethral strictures following coronary artery bypass graft surgery; and when indicated, this type of surgery can be performed with other methods of bladder drainage without increased morbidity.

Tetralogy of Fallot, absent pulmonary valve, partial anomalous pulmonary venous return and coarctation of the aorta.

We describe a unique combination of tetralogy of Fallot, absent pulmonary valve, aortic coarctation with partial anomalous pulmonary venous connection and a retroaortic innominate vein. Surgical repair was successfully accomplished in two stages: coarctation repair preceded correction of the intracardiac anomalies.

Dissection of the left main coronary artery: a complication of PTCA to the anterior descending artery.

This case report describes a patient with severe discrete left anterior descending coronary artery atheroma who underwent percutaneous transluminal coronary angioplasty. During the procedure, dissection occurred in a superior atheromatous plaque of the left main coronary artery and needed immediate surgery. Special care should be taken in the selection and angioplasty of patients with concomitant left main artery disease.

Warm continuous antegrade blood cardioplegia: applications in congenital heart disease.

UNLABELLED: Continuous warm blood cardioplegia is utilized by many surgeons as their method of choice for myocardial protection during operations for acquired heart disease. OBJECTIVE: this study was performed to determine the feasibility and safety of this method for intracardiac procedures through the right atrium and in particular, total cavopulmonary connection. MATERIALS AND METHODS: procedures included closure of an atrial septal defect (23), atrial septectomy (2) and total cavopulmonary connection (4). Antegrade blood cardioplegia was delivered continuously for an average of 27 +/- 21 minutes at an average flow of 130 +/- 60 cc/min to maintain the aortic root pressure between 60 and 80 mmHg (mean 74 +/- 5 mmHg). Perfusion with regular blood commenced in the last 2 to 8 minutes and complete de-airing procedure was performed on the beating heart before removal of the aortic cross-clamp. RESULTS: all patients resumed sinus rhythm and all but one had normal cardiac output postoperatively. In one patient after cavopulmonary connection the inferior vena-cava to pulmonary-artery connection was taken down because of increased pulmonary vascular resistance resulting in low output state. All patients made an uneventful recovery without neurological complications. CONCLUSIONS: this initial experience suggests that normothermic aerobic arrest can be used safely in the repair of congenital defects and may provide superior myocardial protection for complex procedures such as the Fontan procedure.

Arterio-venous fistula in the lower limb in consequence of Fogarty balloon catheter embolectomy. Case report and review of the literature.

Arterio-venous fistula following Fogarty catheter embolectomy is a rare but dangerous complication. The case of a male patient in whom such a fistula was repaired surgically is described. Aggressive approach in the treatment of this severe condition to prevent unnecessary limb loss is advocated. The pertinent literature is reviewed.

Luke warm blood cardioplegia for CAB surgery in patients with severely impaired LV function. Improved results.

Ward blood cardioplegia (WBC) has recently been reported to improve myocardial protection in adult open heart surgery, especially in high risk cases. However, WBC has been reported to have some disadvantages including narrow safety margins concerning brain and kidney perfusion. We therefore modified our technique to utilize luke-warm blood cardioplegia (LWBC). We carried out 470 open heart procedures using luke-warm cardioplegia (anterograde + retrograde perfusion) from 1/2/1991 - 30/9/1992; 94 had LVEF < 30% and form the basis of this study. Other major risk factors in this group included: > 70 yrs - 26 patients, L main > 50% - 14 patients, emergencies - 11 patients, redo's - 3 patients. Eightyone patients underwent CAB only; 3 had additional MVR, 3 additional closure acute VSD of whom one underwent additional LV aneurysmectomy, one additional AVR; 4 patients underwent AVR only, and 2 MVR. Average number of grafts/patient for the 81 isolated CAB's was 4.5. IABP was necessary postbypass in 4 patients (9 emergencies were on IABP support at time of operation). Thirty day mortality was 3 patients (3.2%). Late mortality was 5 cases. These results are superior to those achieved using cold protection and warm blood cardioplegia. LWBC is a safe method for myocardial protection in patients undergoing CAB, particularly when LV function is severely compromised.

Value of dobutamine/nitrate radionuclide angiography in predicting revascularization effects on ventricular function.

OBJECTIVE: Dobutamine and Nitrate Radionuclide Angiography (RNA) may help to distinguish viable from nonviable myocardium and to predict revascularization effects on LV function. SETTING: Ambulatory. EXPERIMENTAL DESIGN: Prospective. PATIENTS AND METHODS: We studied 12 patients (11 male, 1 female; mean age 56 +/- 10 years) with three-vessel disease, severe LV dysfunction, and prior MI for a mean follow-up time of 10 +/- 3.4 months. Thallium-201 scintigraphy favored potential viability in all patients: inducible ischemia with satisfactory perfusion in more than one coronary arterial territory. Global and regional LVEF's were calculated from preoperative RNA (baseline rest study and with continuous dobutamine infusion with gradual rate increase plus oral nitrates) and postoperative RNA at 1 and 6 months. RESULTS: There was no operative mortality, but two late deaths occurred. Symptomatically, most patients showed improvement. Global LVEF increased during dobutamine and nitrates preoperatively (p < 0.01), but not at 1 and 6 months postoperatively (without pharmacological intervention). Mean LVED volume was not significantly changed postoperatively. Regional EF improvement was found in 4 out of 9 LV wall segments under dobutamine and nitrates, and this increase persisted postoperatively at 1 and 6 months. CONCLUSIONS: Mild but significant increase in global LVEF during dobutamine and nitrates administration is not predictive of postoperative LVEF improvement. However, regional EF improvement appears to be predictive of post-revascularization LV functional improvement.