Effect of preoperative supplementation with alpha-tocopherol and ascorbic acid on myocardial injury in patients undergoing cardiac operations.

Augmentation of antioxidant defenses may help protect tissues against ischemia-reperfusion injury associated with operations involving cardiopulmonary bypass. In this study we examined the effect of pretreating patients with alpha-tocopherol (vitamin E) and ascorbic acid (vitamin C) or placebo on injury to the myocardium. Seventy-six subjects undergoing elective coronary artery bypass grafting participated in a prospective, double-blind, placebo-controlled randomized trial, receiving either placebo or both 750 IU dl-alpha-tocopherol per day for 7 to 10 days and 1 gm ascorbic acid 12 hours before the operation. Plasma alpha-tocopherol concentrations, raised fourfold by supplementation, fell by 70% after the operation in the supplemented group and to negligible levels in the placebo group. There were no significant differences between the groups with respect to release of creatine kinase MB isoenzyme over 72 hours, nor in the reduction of the myocardial perfusion defect determined by thallium 201 uptake. Electrocardiography provided no evidence of a benefit from antioxidant supplementation. Thus the supplementation regimen prevented the depletion of the primary lipid soluble antioxidant in plasma, but provided no measurable reduction in myocardial injury after the operation.

Mycotic false aneurysm of the aortic suture line after heart transplantation.

Aortic suture line infection caused by Pseudomonas aeruginosa occurred in a 31-year-old man 2 months after orthotopic heart transplantation. Incomplete resection of the mycotic aneurysm and replacement of the ascending aorta with allograft aorta was performed. Subsequently, the infection recurred on the proximal suture line, and reoperation with complete excision of the mycotic aneurysm and allograft replacement of the ascending aorta was performed successfully, without recurrence of the infection.

The Medtronic Intact xenograft: an analysis of 342 patients over a seven-year follow-up period.

Three hundred forty-two patients from December 1985 to January 1993 received 352 Medtronic Intact porcine xenograft valves (zero-pressure glutaraldehyde-fixed with toluidine blue anticalcification agent). The follow-up was 99.4% complete with a mean of 3.14 years (3 months to 7.9 years). The mean patient age was 64 years (range, 16 to 82 years) and the median age was 67 years. There were 14 aortic valve replacement patients (11.9%) and 62 mitral valve replacement patients (29.2%) who preoperatively were in New York Heart Association class IV to V. The hospital mortality was 8.4% +/- 2.9% (aortic valve replacement, 5.9%; mitral valve replacement, 9.4%; tricuspid valve replacement, 7.6%). Actuarial patient survival at 7 years was 65% +/- 5% (aortic valve replacement, 77% +/- 5%; mitral valve replacement, 63% +/- 5%). At 7 years, the freedom from thromboembolism was 74% +/- 4%, freedom from endocarditis 93% +/- 2%, and freedom from reoperation 90% +/- 3%. Reoperation was required for endocarditis (7 patients), periprosthetic leak (6), and 2 of 3 cases of structural deterioration. The actuarial freedom from structural deterioration at 5 years was 97% +/- 3%. The combined incidence of all important morbid valve-related events was analyzed with an actuarial freedom at 7 years of 63% +/- 3%. The durability of the Medtronic Intact is at least equal to that of other porcine bioprostheses. The relevant important time-frame of 7 to 12 years of follow-up has just begun, and possibly the reoperation rate for intrinsic value failure and the low incidence of calcification in the elderly patient may be showing improved characteristics of this valve. No stronger inferences are possible at this stage of the 7-year follow-up.

Allograft aortic valve replacement: long-term follow-up.

Aortic valve replacement using an allograft aortic valve has been performed on 804 patients. From December 1969 to May 1975, 124 patients received a nonviable allograft valve sterilized by incubation with low-dose antibiotics and stored for weeks by refrigeration at 4 degrees C (series 1). From June 1975 to January 1994, 680 patients received viable allograft valves, now cryopreserved early within 2 hours of collection from transplant recipient donors, 6 hours for multiorgan donor valves and 23 hours (mean) for autopsy valves from donor death. The 30-day mortality was 8.9% +/- 5% (95% confidence limits) for series I and 2.8% +/- 1% (95% confidence limits) for series II. Actuarial patient survival including hospital mortality at 15 years was 56% +/- 5% for series I and 62% +/- 5% for series II. The probability of a thromboembolic event was low, freedom at 15 years being 95% +/- 1% for patients receiving allografts with or without associated coronary bypass procedures and 81% +/- 5% for patients having allografts with other associated procedures (eg, mitral valve operations). Actuarial freedom from endocarditis was similar for the two series, 91% +/- 3% (series I) and 94% +/- 2% (series II) at 15 years. The freedom from valve incompetence, from reoperation for all causes, and from structural deterioration demonstrated clearly the inferiority of the 4 degrees C stored allograft valves. For structural deterioration as identified clinically, at reoperation and at death, freedom from this event at 15 years was 45% +/- 6% for series I and 80% +/- 5% for series II (p value for the difference is 0).(ABSTRACT TRUNCATED AT 250 WORDS)

Root replacement for all allograft aortic valves: preferred technique or too radical?

From November 1985 to January 1994, 146 patients have received a viable cryopreserved allograft for aortic root replacement. The follow-up was complete, with all events included to March 1st, 1994. The median age of patients was 49 years; 83.6% were male. Valve dysfunction (91 patients), primary aortic wall disease (45 patients), and a combination of both (10 patients) were the indications for aortic root replacement. The current operative mortality is 1.7% (three deaths in 172 patients to July 1st, 1994). Four late deaths have occurred, with an 8-year actuarial survival of 85% +/- 8% (95% confidence limits). Endocarditis (two events) and thromboembolism (four events) had a low incidence. Structural deterioration (three events) and reoperation for all causes (nine events) have constituted low morbidity and are compared with the results after non-root allograft implantation techniques. The clinical and echocardiographic evidence indicates that the immediate results of valve function with root replacement are superior. But no statistical difference between aortic root replacement and non-root procedures is apparent at 8 years, indicating that a longer follow-up is required before the answer to the question "preferred technique or too radical" can be answered.

Late complications of tissue glues in aortic surgery.

BACKGROUND: Tissue glues are used in cardiothoracic surgery as an adjunct to operative procedures where tissues are frail, as in aortic dissection, or where added hemostasis is required. This study was undertaken to review the use of tissue glue in our institution over a 5.5-year period. The aim of the study was to identify any potentially glue-related complications. METHODS: A review of tissue glue use for the period from January 1993 to September 1998 was performed and pre-, intra-, and postoperative parameters were collected. After some unusual surgical findings, of special interest was a range of pathology found at late reoperation. RESULTS: A total of 67 cases of tissue glue use were identified, with the majority of operations for type A dissection (76%). There were two intraoperative deaths. Twenty-seven of 65 patients (41%) required 29 further open chest operations; of these, 17 were for acute problems of bleeding or tamponade. Twelve patients (18%) underwent late reoperations months to years later. Nine of these patients, concentrated in two operative groups (7 patients with aortic valve resuspension and 2 patients who had undergone "switch" operations for transposition of great vessels), displayed complications related to the application of gelatin-resorcinol-formaldehyde (GRF) tissue glue. CONCLUSIONS: Indications for tissue glues in cardiothoracic surgery must be carefully considered. We have reviewed our use of some tissue glues in acute type A aortic dissections and in pediatric cardiac patients and have discontinued the use of GRF glues because of unsatisfactory long-term complications.

The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.

BACKGROUND AND AIM OF THE STUDY: The study aim was to elucidate the advantages and limitations of the homograft aortic valve for aortic valve replacement over a 29-year period. METHODS: Between December 1969 and December 1998, 1,022 patients (males 65%; median age 49 years; range: 1-80 years) received either a subcoronary (n = 635), an intraluminal cylinder (n = 35), or a full root replacement (n = 352). There was a unique result of a 99.3% complete follow up at the end of this 29-year experience. Between 1969 and 1975, homografts were antibiotic-sterilized and 4 degrees C stored (124 grafts); thereafter, all homografts were cryopreserved under a rigid protocol with only minor variations over the subsequent 23 years. Concomitant surgery (25%) was primarily coronary artery bypass grafting (CABG; n = 110) and mitral valve surgery (n = 55). The most common risk factor was acute (active) endocarditis (n = 92; 9%), and patients were in NYHA class II (n = 515), III (n = 256), IV (n = 112) or V (n = 7). RESULTS: The 30-day/hospital mortality was 3% overall, falling to 1.13 +/- 1.0% for the 352 homograft root replacements. Actuarial late survival at 25 years of the total cohort was 19 +/- 7%. Early endocarditis occurred in two of the 1,022 patient cohort, and freedom from late infection (34 patients) actuarially at 20 years was 89%. One-third of these patients were medically cured of their endocarditis. Preservation methods (4 degrees C or cryopreservation) and implantation techniques displayed no difference in the overall actuarial 20-year incidence of late survival endocarditis, thromboembolism or structural degeneration requiring operation. Thromboembolism occurred in 55 patients (35 permanent, 20 transient) with an actuarial 15-year freedom in the 861 patients having aortic valve replacement +/- CABG surgery of 92% and in the 105 patients having additional mitral valve surgery of 75% (p = 0.000). Freedom from reoperation from all causes was 50% at 20 years and was independent of valve preservation. Freedom from reoperation for structural deterioration was very patient age-dependent. For all cryopreserved valves, at 15 years, the freedom was 47% (0-20-year-old patients at operation), 85% (21-40 years), 81% (41-60 years) and 94% (>60 years). Root replacement versus subcoronary implantation reduced the technical causes for reoperation and re-replacement (p = 0.0098). CONCLUSION: This largest, longest and most complete follow up demonstrates the excellent advantages of the homograft aortic valve for the treatment of acute endocarditis and for use in the 20+ year-old patient. However, young patients (< or = 20 years) experienced only a 47% freedom from reoperation from structural degeneration at 10 years such that alternative valve devices are indicated in this age group. The overall position of the homograft in relationship to other devices is presented.

Haemodynamics and left ventricular mass regression: a comparison of the stentless, stented and mechanical aortic valve replacement.

OBJECTIVE: Our objective was to compare the degree of change in hemodynamics and left ventricular mass (LVM) regression after aortic valve replacement (AVR) with stentless, stented and mechanical valves. METHODS: Patients greater than 59 years of age had AVR for aortic stenosis with the stentless xenograft (Cryolife-O'Brien, CLOB), stented xenograft (Carpentier-Edwards, C-E) or mechanical valve (ATS). One-hundred and forty-two patients received stentless, 40 stented, and 69 mechanical valves (mean age 74 +/- 6 vs. 72 +/- 7 and 67 +/- 6 years, respectively). Serial echocardiography was performed. RESULTS: The left ventricular outflow tract diameter was similar pre-operatively in the stentless versus the stented versus the mechanical groups (2.2 +/- 0.4 vs. 2.3 +/- 0.2 vs. 2.2 +/- 0.3 cm; P, n.s). The effective orifice area was larger immediately post-operatively in the stentless versus the stented or the mechanical group (2.4 +/- 0.4 vs. 2.0 +/- 0.6 vs. 2.0 +/- 0.7 cm2, P = 0.0001 for both comparisons). The peak aortic gradient at 6 months was significantly less in the stentless versus the stented and mechanical groups (15 +/- 7 vs. 25 +/- 9 vs. 22 +/- 9 mmHg, P < 0.0001). LVM regressed over 6 months in all subgroups: stentless 272 +/- 64 g vs. 220 +/- 72 g, P = 0.0001, stented 257 +/- 58 vs. 230 +/- 74 g, P = 0.02, and mechanical 267 +/- 95 vs. 204 +/- 54 g, P = 0.003. The reduction in LVM was greater in the stentless versus the stented (P = 0.05) but similar to the mechanical group. CONCLUSIONS: AVR with the stentless xenograft results in superior hemodynamics compared to the stented and mechanical valve replacements. AVR in all three groups leads to a significant regression of left ventricular hypertrophy within 6 months. However the reduction in LVM is greater in subjects with stentless and mechanical valves, which may have prognostic significance.

Torrential rectal bleeding. An unusual presentation of colonic carcinoma.

A case of torrential rectal bleeding due to a colonic carcinoma is reported. The clinical diagnosis was confirmed by angiography, which showed an abnormal circulatory pattern at the hepatic flexure of the colon. Resection of the tumour controlled the bleeding. Dealing with this clinical problem requires a systematized approach. Angiographic demonstration of the source of the bleeding allows definitive surgical management.

Lymphangitis carcinomatosa.

A case of lymphangitis carcinomatosa secondary to a primary gastric adenocarcinoma is reported. Diagnosis was suspected clinically and radiologically, but was established only at autopsy. The condition is reviewed. When suspected, transbronchial lung biopsy would allow histological confirmation of the diagnosis.

Scleromalacia perforans in ulcerative colitis.

Ulcerative colitis is associated with many ocular complications. The only systemic disease currently recognized to be complicated by scleromalacia perforans is rheumatoid arthritis. A 36-yr-old male is described whose long-standing ulcerative colitis was complicated by scleromalacia perforans at a time of disease activity. The scleromalacia was successfully treated with high-dose steroids and total proctocolectomy.