Intraaortic balloon pump insertion: a randomized study comparing percutaneous and surgical techniques.

To compare the percutaneous and surgical techniques of intraaortic balloon pump insertion, 101 patients referred for this procedure were randomly assigned to either percutaneous or surgical insertion. Insertion using the designated technique was successful in 45 (88%) of 51 patients with percutaneous insertion and 48 (96%) of 50 patients with surgical insertion (difference not statistically significant). The time from the beginning of the insertion procedure to the initiation of counterpulsation was 13 +/- 8 minutes for the percutaneous technique versus 31 +/- 16 minutes for the surgical technique (p less than 0.001). In the percutaneous group, 10 patients required Fogarty thrombectomy after balloon pump removal, and 1 patient developed severe leg ischemia requiring immediate termination of balloon pump support. In the surgical group, one patient developed leg ischemia requiring surgical intervention, three patients developed sepsis with bacteremia (including one patient who required vein patch repair of the femoral artery), one patient developed a wound infection requiring debridement and one patient had a cerebral embolus. Aortic dissection, aortoiliac perforation or amputation did not occur in either group. Major vascular complications occurred in 11 patients (22%) with percutaneous insertion versus 2 patients (4%) with surgical insertion (p less than 0.05). It is concluded that although the percutaneous technique for intraaortic balloon pump insertion is faster than the surgical technique and is technically easy, it is associated with a higher incidence of vascular complications.

A method for generating obstructive thrombi in the coronary arteries of the conscious dog.

A technique for staging the generation of obstructive thrombi in the coronary arteries of conscious dogs is described. At thoracotomy, electrodes are placed in the lumina of coronary artery branches. When thrombus generation in proximity to the intraluminal electrode tip is desired, anodal current is applied to the exteriorised end of the electrode. In each of nine anaesthetised adult mongrel dogs two to seven intracoronary electrodes were implanted for a total of 35. One to 75 days later, 50 to 800 microA anodal current was applied to 16 electrodes for 30 min to 48 h. Upon autopsy, thrombi in various stages of organisation were found in proximity to the intracoronary portion of 15 electrodes. Six electrodes were found to be damaged or broken. In contrast, only four of the 13 control electrodes were sites of thrombus formation. In seven dogs tissue sections indicated either myocardial ischaemia or infarct in regions whose perfusion was blocked by thrombi. This method may provide for discretionary generation of intracoronary thrombi in the desired quantity, at the preferred site(s), at selected times of onset. Consequently, it offers the possibility of adjusting the onset, severity, and time course of myocardial ischaemia.

Intraaortic balloon pumping for prolonged circulatory support.

Prolonged circulatory support with an intraaortic balloon pump (IABP) is controversial, in part because it has not been performed frequently enough to base treatment policy on adequate data. To help clarify this problem, 733 cases of consecutive patients who were supported by IABP between 1967 and 1982 were analyzed. Twenty-seven patients were supported for 20 days or more (range 20 to 71). Twelve (44%) had prior histories of chronic congestive heart failure. Complications were more frequent in prolonged-support patients than in those assisted for less than 20 days (vascular, 37% vs 15%, p = 0.001; infectious, 67% vs 25%, p = 0.0001; and bleeding, 26% vs 15%, p = 0.04, respectively). The survival rate of prolonged-support patients, however, was 63% (17 of 27), essentially the same as that of the controls (57%, p = 0.5). Of 17 prolonged-pumping patients discharged alive from the hospital, 9 died within 6 months but 8 survived greater than 2 years. Among congestive heart failure patients, none was a long-term survivor. Prolonged IABP support in congestive heart failure patients lacking surgically correctable lesions can extend life while arrangements for definitive therapy are made (transplant, permanent mechanical assistance). Where definitive therapy is unavailable, IABP may provide additional months of life.

Intraaortic balloon pumping 1967 through 1982: analysis of complications in 733 patients.

Between June 1967 and December 1982, 872 attempts at intraaortic balloon pumping (IABP) were made in 733 patients. Nearly 75% of the patients were men; the proportion of women has increased in recent years. The principal indication for IABP support initially was cardiogenic shock, but over the years, preoperative support, weaning from cardiopulmonary bypass and unstable angina have become the primary indications. Complications of IABP were classified and distributed by severity (minor: I [15%] and II [26%]; major: III [3%] and IV [1%]) and type ([vascular [22%], infectious [22%], and bleeding [7%]). Vascular complication rates were higher in women (32 vs 18%; p = 0.0001), in diabetic patients (32 vs 20%, p = 0.003), and in hypertensive patients (27 vs 20%, p = 0.02). These did not vary with the duration of IABP support (range of duration 0 to 76 days). The rate of infectious complications was related to location where IABP was performed (coronary care unit 26%, operating room 12%). The rate of fever and bacteremia increased significantly with duration of IABP support, but the rate of local wound infection did not. In conclusion, most IABP complications are minor, resolve after balloon removal, are related to vascular status of the patient and, with the exception of bacteremia, are independent of IABP duration.

Risks associated with intraaortic balloon pumping in patients with and without diabetes mellitus.

Between 1967 and 1982, intraaortic balloon pumping (IABP) was attempted in 733 patients. Of these, 132 were diabetic: 51 patients were managed with diet alone, 46 patients took oral hypoglycemic agents and 35 patients required insulin. Vascular complications associated with IABP occurred in 34% of the insulin-dependent diabetics, in 18% of other diabetics and in 14% of nondiabetic patients. Infectious complications were 37, 22 and 25%, respectively. Seventy-five diabetic patients (57%) were discharged alive from the hospital after balloon pumping, essentially the same proportion as among nondiabetic patients (58%). It is concluded that although diabetics incur a higher complication rate, IABP is not contraindicated.

Hemodynamic effects of venous valves in aorto-coronary bypass grafts.

Use of the saphenous vein in aorto-coronary bypass surgery for treatment of occlusive coronary artery disease is a well-established technique. Use of the mammary artery for the same purpose has also been favorably reported. This study was undertaken to determine whether a vein graft containing a valve would have an added advantage. A comparison of the effect of competent and incompetent valves in vein grafts on the hemodynamics of coronary circulation was made. In a group of 18 dogs, a 5 cm. portion of each dog's cephalic vein containing a valve was used in a single aorto-coronary bypass graft. Flow measurements were made between the valve and the anastomosis of the graft to the left anterior descending coronary artery (LAD). The valve was made temporarily incompetent by the insertion of a spring wire basket, 3.5 mm. in diameter, through the valve via a side branch. The flow of blood through the venous graft with the competent valve was 11.0 +/- 2.6 per cent higher than with the incompetent valve. An analysis of flow patterns showed that this increased flow could be attributed to a reduction of backflow during systole and an increase in forward diastolic flow. Results suggest that postoperative myocardial perfusion is enhanced by the presence of valves in aorto-coronary bypass vein grafts.

Permanent in-series cardiac assistance with the dynamic aortic patch: Blood-prosthesis interaction in long-term canine experiments.

The blood-prosthesis interaction of the dynamic aortic patch (DAP), an in-series assist device for permanent circulatory support which is implanted in the descending thoracic aorta, was studied in 65 long-term experiments. Periods of postoperative observation with the device inactive or activated ranged from 2 weeks to 22 months. The intravascular surface of the DAP, fabricated of Dacron velour backed by bioelectric polyurethane, displayed various degrees of organization, ranging from a thin fibrin layer to a well organized pseudointima. Activation of the system did not prevent the development of an organized pseudointima. Changes in free-plasma hemoglobin were minimal; platelet count per square millimeter and state of reactivity remained within normal limits. Evidence of renal embolization, attributable to activation of the device, was found in five animals. Frequent lethal complications were aortic rupture and infections of the thoracic cavity originating at the implantation site. Further improvement of the DAP and the techniques of implantation is indicated to insure its efficacy during long-term implantation and activation.

Patient selection for cardiac surgery in left ventricular power failure.

Nineteen patients in acute left ventricular power failure following acute myocardial infarction were given support with intraaortic balloon pumping and underwent cardiac catheterization. Hemodynamic response to disastolic augmentation, results of left ventriculography, and observations of selective coronary arteriography were evaluated to determine which patients could survive without operation, which would require operation to survive, and which could be predicted not to survive operation. Of ten patients who underwent operation, three were long-term survivors. Two patients predicted to have a good prognosis without surgery did survive. Of three patients who had been determined to require operation but not undergo it, two died in the hospital and one a month later. The four patients whose conditions were considered inoperable died in the hospital. The results indicate that current methods of predicting the need for corrective surgery are relatively accurate and that the rate of survival in surgically treated patients may be increased.

Origins of intraaortic balloon pumping.

In 1968, the Journal of the American Medical Association published a paper on the "Initial clinical experience with intraaortic balloon pumping in cardiogenic shock," which gave the results of the first clinical use of the procedure developed in our laboratory. For more than 2 years, our group was the only one using intraaortic balloon pumping clinically. Later, intraaortic balloon pumping was used by others, and despite poor clinical salvage, the hemodynamic benefit was demonstrated convincingly. At the present time, approximately 70,000 balloon pump procedures are performed annually.

Simplified circular aortotomy in aortocoronary bypass operations.

Adaptation of a rongeur technique facilitates aortotomy in aortocoronary bypass operations. A single motion with a double-action duckbilled rongeur produces a smooth-walled, symmetrical aortotomy which varies in shape predictably according to the angle at which the rongeur is held relative to the axis of the aorta.

An extravascular left ventricular assist device.

The hemodynamic efficacy and prosthesis-vessel interaction of a pneumatically activated circulatory assist device was investigated in 12 acute and 12 chronic studies in dogs. A polyurethane balloon encased in Dacron-velour cloth was fastened to the descending thoracic aorta with a spiral wrapping of Dacron graft material. Diastolic augmentation was provided by rhythmic inflation and deflation of the balloon. Hemodynamic results, based on 5 dogs with experimental myocardial ischemia, showed that left ventricular systolic peak pressure decreased by 8.2 +/- 1.9%, cardiac output increased by 13.1 +/- 2.8%, and circumflex coronary artery flow rose by 17.5 +/- 2.5%. In the chronic experiments the prosthesis was asynchronously but continuously activated from one to sixteen weeks at 74 cycles per minute. Postmortem examination of the implantation site in all 12 dogs showed that necrosis had developed but was limited to the outer half of the medial layer beneath the pumping chamber and that the aortic wall was compressed to about 70% of its original thickness. Although the method described represents a simple form of providing ventricular assistance, its applicability for long-term circulatory support remains to be evaluated.

Use of neurosurgical techniques for removal of a cardiac tumor.

A 6-week-old male infant with a capillary hemangioma of the right atrioventricular groove adjacent to the right coronary artery and conduction system underwent successful resection with the aid of microneurosurgical instrumentation. The technical challenge was thought to be analogous to that encountered by microneurosurgeons in their dissection of brain tumors.

Pregnancy-associated subacute hemorrhage into a prolactinoma resulting in diabetes insipidus.

A young woman with a small pituitary tumor associated with hyperprolactinemia developed subacute intrapituitary hemorrhage during the third trimester of pregnancy and presented with central diabetes insipidus. Magnetic resonance imaging established the diagnosis. After transsphenoidal surgery, her visual findings resolved, and the patient had an uneventful spontaneous delivery.

Transcallosal, transventricular approach to a basilar apex aneurysm.

A new approach to the basilar apex in a patient with a megadolichobasilar anomaly and an abnormally rostral basilar apex aneurysm is described. The details of the surgical approach and the advantages and limitations of this transcallosal, interseptal approach are described.

Erythropoietin-augmented isovolemic hemodilution in skull-base surgery. Case report.

Human erythropoietin in concert with intraoperative hemodilution, tumor embolization, and surgical staging was used to manage a red blood cell mass in an anemic Jehovah's Witness patient with a hypervascular meningioma. Erythropoietin (3000 U thrice weekly) and oral iron (1300 mg daily) were given for 1 month prior to surgery, raising the hemoglobin level from 11.8 to 14.1 gm/100 ml. A posterior fossa craniectomy combined with a temporal craniectomy was then performed so that partial petrosectomy, section of the transverse sinus, incision of the tentorium, and exposure of the lesion could be carried out. The first stage of the surgery was terminated immediately prior to tumor mobilization. Isovolemic hemodilution was initiated just before the skin incision. Postoperatively, the hemoglobin concentration dropped to 11.5 gm/100 ml. The erythropoietin dose was doubled and administration of oral iron continued, leading to a hemoglobin level of 14.0 gm/100 ml at 1 month after the first operation. The tumor was embolized using superselective catheterization. The next day, at the second stage of the surgery, the tumor was extirpated, again employing isovolemic hemodilution. By the 4th postoperative day, the hemoglobin level had dropped to 9.4 gm/100 ml. The patient made an uncomplicated recovery. Erythropoietin therapy contributed substantially to the successful outcome of this case. Since erythropoietin has the potential to augment all other forms of autologous banking, its role in elective neurosurgery may become increasingly important in an era of heightened concern about heterologous transfusion.

Split-calvaria osteoplastic rotational flap for anterior fossa floor repair after tumor excision. Technical note.

A split-calvaria osteoplastic rotational flap to repair the anterior fossa floor after tumor excision was devised and tested clinically. At surgery, the flap is outlined between the glabella and the vertex. After the pericranium between the glabella and the flap's anterior pole is elevated to form its pedicle, a full-thickness craniotomy is performed to expose the diploic aspect of the bone graft donor site (when the graft is relatively wide, bifrontal craniotomies may be advantageous). The diploic space is split in situ, taking care to protect the pedicle and its attachments to the osseous segment. Linear osteotomies in the outer table are created to mobilize the flap. With the flap rotated frontally, the craniotomy is completed. After tumor extirpation, the margins of the osseous segment of the flap are shaped to conform to the defect of the anterior fossa floor. Transverse osteotomies are performed so that the graft's convex curve conforms to that of the anterior fossa floor. The flap is then rotated into position. Follow-up evaluation in two patients at 22 and 30 months demonstrated bone integrity of the anterior fossa floor with graft preservation. Transient postoperative cerebrospinal fluid (CSF) rhinorrhea, which occurred in Case 1, was avoided in Case 2 by placing the osseous segment of the graft coplanar with the bone floor of the fossa. Neither patient had late meningitis or CSF rhinorrhea. The split-calvaria osteoplastic rotational flap may represent an advance toward the ideal reconstruction of the anterior cranial fossa floor.

Percutaneous intra-aortic balloon counterpulsation.

Intra-aortic balloon pumping is the mainstay in the management of acute left ventricular dysfunction in the critical care setting. Percutaneous insertion affords rapid initiation of the procedure. Complications are in greatest part vascular and infectious. The advent of new-generation, totally automatic, closed-loop IABP systems offers the prospect of increasing the effectiveness of IABP support under most conditions, and especially during arrhythmias. This and other developments suggest that despite its standing as the most widely used temporary cardiac assist device, IABP has still to realize its full therapeutic potential.

Transoral-transclival clipping of a giant lower basilar artery aneurysm.

The authors discuss the choice of the transoral-transclival approach for the repair of a lower basilar artery aneurysm in a 32-year-old sickle-cell patient. Efficiency of approach and minimization of damage to vital structures support the use of this technique. The risks of cerebrospinal fluid fistula and meningitis are considered. One year after operation, the patient is neurologically intact.