Use of the Hemobag for modified ultrafiltration in a Jehovah's Witness patient undergoing cardiac surgery.

Modified ultrafiltration is an important technique to concentrate the patient's circulating blood volume and the residual whole blood in the extracorporeal circuit post-cardiopulmonary bypass. The Hemobag system is a device cleared by the US Food and Drug Administration and represents a novel and safe modification of traditional modified ultrafiltration systems. It is quick and easy to operate by the perfusionist during the hemoconcentration process. Hemoconcentration is accomplished by having the Hemobag "recovery loop" circuit separate from the extracorporeal circuit. This allows the surgeons to continue with surgery, decannulate, and administer protamine simultaneously while the Hemobag is in use. The successful use of the Hemobag in a Jehovah's Witness patient has not been previously described in the literature. This case report describes how to set up and operate the Hemobag in a Jehovah's Witness patient undergoing cardiac surgery that requires an extracorporeal circuit.

Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement.

BACKGROUND: Ideal perfusion during ascending aorta-arch surgery should allow easy implementation of antegrade cerebral perfusion while avoiding atheroembolization or false lumen perfusion in dissections. We report favorable experience with direct axillary artery cannulation. METHODS: Between 1999 and 2003, 284 patients with a mean age of 62.2 years (25 to 85), underwent axillary artery cannulation using a right angle wire-reinforced catheter. During this interval, attempted axillary cannulation was abandoned in only 14 patients because of inadequate backflow or other complications. Eighty-five patients were female. Severe aortic arteriosclerosis or degeneration was present in 209, aortic dissection in 63, and Marfan disease or aortitis in 12. The Bentall procedure was done in 144 patients, arch replacement in 86, the Yacoub procedure in 18, thoracoabdominal aneurysm repair in 16, and coronary artery bypass grafting in 20. Reoperations were at 30.2%. RESULTS: Adverse outcome (hospital death or permanent stroke) occurred in 6.6% (n = 19). Thirteen patients (4.6%) died before hospital discharge, and 13 patients (4.6%; 9 of whom died) suffered permanent stroke. Transient neurologic dysfunction occurred in 9.2% (n = 26). Mean duration of hypothermic circulatory arrest, used in 246 patients, was 26 +/-7 minutes. Mean duration of antegrade cerebral perfusion, used in 139 patients, was 47 +/- 23 minutes. In 93%, the right axillary artery was cannulated. Complications included 2 cases (0.7%) of brachial plexus injury (one transient), and 3 (1%) of localized dissection. CONCLUSIONS: Our results suggest that axillary artery cannulation, successful in 95% of patients, may be the optimal technique for reducing perfusion-related morbidity and adverse outcome in operations for acute dissection, atherosclerotic, and degenerative aneurysmal disease. It deserves serious consideration in all patients older than 65 requiring cardiopulmonary bypass.

Technical advances in total aortic arch replacement.

BACKGROUND: We compared the effects of using hypothermic circulatory arrest (HCA) alone, HCA combined with selective cerebral perfusion (SCP), and use of SCP with a trifurcated graft (T) on outcome after aortic arch repair. METHODS: One hundred fifty patients, median age 66 years (range, 27 to 85), underwent total arch replacement between 1988 and 2002; 75 were female. We retrospectively compared the results of three patient groups roughly comparable with regard to preoperative risk factors: 45 patients using HCA beginning in 1988; 67 patients using HCA/SCP beginning in 1994; and 38 patients utilizing a trifurcated arch graft in conjunction with SCP through the axillary artery (HCA/SCP/T) since 2000. The groups were well matched with regard to median age (66, 68, and 66 years), urgency (emergent 11%, 13%, 5%; urgent 24%, 9%, 18%; and elective 64%, 78%, 76%), and several other known risk factors (p = not significant). RESULTS: An adverse outcome-hospital death or permanent stroke-occurred in 14%: in 16% with HCA, in 16% with HCA/SCP, and in 8% with HCA/SCP/T. Transient neurologic dysfunction among patients surviving without stroke was lower with HCA/SCP/T (11%) than with HCA (33%) or HCA/SCP (17%). Mean duration of HCA was 52 +/- 16 minutes with HCA alone versus 45 +/- 10 minutes with HCA/SCP and 31 +/- 7 minutes with HCA/SCP/T (p < 0.0001 for groups HCA and HCA/SCP combined versus HCA/SCP/T). Mean duration of SCP was 57 +/- 25 minutes with HCA/SCP versus 62 +/- 24 minutes with HCA/SCP/T (p = not significant). Comparison of the groups of patients who had comparable preoperative risk factors for adverse outcome showed a trend toward lower adverse outcome and transient neurologic dysfunction rates using HCA/SCP/T; a significant reduction in respiratory (p < 0.001), infectious (p = 0.015) and cardiac (p = 0.005) complications in HCA/SCP/T compared with the earlier groups; and significantly shorter durations of intensive care (p < 0.0001) and hospitalization (p = 0.004). CONCLUSIONS: Our results suggest that HCA/SCP is superior to HCA alone for preventing cerebral injury during operations on the aortic arch. By further reducing embolic risk as well as duration of HCA, HCA/SCP/T with axillary artery cannulation may be the optimal technique for averting adverse outcomes, reducing complications, and shortening hospital stay after aortic arch repair.

Description of a new technique for reimplanting the anomalous right pulmonary artery.

Anomalous origin of the right pulmonary artery from the ascending aorta is a rare congenital lesion with a high mortality and morbidity if early diagnosis is not made and correction is not undertaken. We describe the repair of such a lesion using a double-trapdoor technique of pulmonary artery reimplantation.