Risk analysis in patients bridged to transplantation.

BACKGROUND: Efforts to predict mortality in bridge to cardiac transplant patients have concentrated on preventricular assist device (VAD) status. To more fully identify factors influencing survival to transplant, we reviewed the preoperative and postoperative VAD courses of 105 bridge to transplant patients. METHODS: Sixty-four parameters (34 pre-VAD, 30 post-VAD), including hemodynamics, complications, and evaluations of major organ function were examined and analyzed. RESULTS: Thirty-three patients (31%) died on VADs and 72 were transplanted. There were two posttransplant operative deaths (3%). By univariate analysis 23 of 64 factors were significant. These 23 factors were entered into a stepwise logistic regression analysis to identify predictors of survival to transplant. Four factors, including pre-VAD intubation (p < 0.005), cardiopulmonary bypass (CPB) time during VAD insertion (p < 0.0001), mean pulmonary artery pressure (first postoperative day after VAD) (p < 0.0002), and highest post-VAD creatinine (p < 0.01) were independent predictors of transplantation. CONCLUSIONS: Other than the need for intubation, pre-VAD variables were of little value in predicting survival to transplant. Problems during VAD insertion (long CPB time) and post-VAD renal insufficiency were independent predictors. Severe complications that developed during the interval of VAD support, including cerebrovascular accident, bleeding and infection, were surprisingly not predictors for transplantation.

Aberrant origin of the left coronary artery from the right aortic sinus: surgical intervention based on echocardiographic diagnosis.

An athletic 15-year-old girl with aberrant left coronary artery from the right coronary sinus, presented with syncope during exercise. Trans-thoracic echocardiography was the only imaging technique that clearly demonstrated her anomaly. The results of magnetic resonance and selective coronary angiographic imaging were inconclusive. Surgical intervention was successfully performed on the basis of the echocardiographic diagnosis.

Major leg wound complications after saphenous vein harvest for coronary revascularization.

BACKGROUND: Major leg wound complications after coronary artery bypass graft procedures are infrequent and few are reported in the literature. We present our experience in treating 23 patients with major leg wound complications after coronary revascularization procedures. METHODS: A retrospective review of 3,525 bypass procedures with saphenous vein grafts performed over a 10-year period was conducted. Ten potential risk factors for those who developed major leg wound complications were analyzed and compared with the entire cohort of patients undergoing similar bypass procedures during the same period. RESULTS: Lower extremity wound complications occurred in 145 patients (4.1%), 23 of whom (0.65%) required additional surgical interventions (62 total). There were 32 wound debridements, 8 skin grafts, 11 vascular procedures, 5 amputations, 3 fasciotomies, 2 free tissue transfers, and 1 fasciocutaneous flap. Of ten variables evaluated by multivariate analysis, female gender, peripheral vascular disease, and postoperative intraaortic balloon pump use were identified as significant independent predictors of major leg wound complications (p < 0.0001). CONCLUSIONS: The causes of major leg wound complications after saphenous vein harvest for coronary artery bypass graft procedures are multifactorial. To minimize these complications, we recommend vascular evaluations before saphenous vein harvest, attention to proper surgical technique, and careful harvest site selection.

Transfer of patients receiving advanced mechanical circulatory support.

OBJECTIVE: Improving results with ventricular assist devices have led to their wider clinical application. Centers can stabilize, support, and wean or transfer patients to regional transplant centers. METHODS: Prospectively collected data were reviewed to evaluate the clinical results of patients transferred to our institution while receiving advanced mechanical circulatory support. RESULTS: Since 1993, 16 patients were accepted while receiving support with either extracorporeal membrane oxygenation or a ventricular assist device. The 10 male and 6 female patients ranged in age from 9 to 60 years (mean, 42.1 years). Thirteen had had cardiac surgical procedures, two had acute myocardial infarctions, and one had myocarditis. The distance transported ranged from 0.2 to 309 miles (mean, 132 miles). Twelve patients were transferred by ground, and 4 were transported by air. Seven patients were originally supported with extracorporeal membrane oxygenation, 6 with centrifugal pumps, and 3 with ABIOMED ventricular assist devices (ABIOMED, Inc, Danvers, Mass). Two patients had clinical complications during transfer, and one had a cerebrovascular accident, recovered, was weaned, and survived. A second patient had hemodynamic deterioration. There were no technical complications associated with transport. Six patients were left on the original support device; 3 of the 6 were weaned and survived, and 3 died during support. The 10 remaining patients were switched to other ventricular assist devices: 9 patients to Thoratec devices (Thoratec Laboratories, Pleasanton, Calif) and 1 patient to a Novacor device (Baxter Healthcare Corp, Novacor Division, Oakland, Calif). Six of the 10 patients underwent transplantation and survived. Four patients died while being supported by the devices. Nine patients were discharged, with 1 late death at 29 months. Eight patients are alive 4 to 65 months after discharge. CONCLUSIONS: These data suggest that patients receiving advanced support can be moved between clinical centers with acceptable risks. Because 33% of the survivors were weaned, transplantation is not required for survival.

Coronary artery to pulmonary artery collaterals after heart transplantation.

Collaterals are described between coronary and pulmonary arteries after orthotopic heart transplantation. It is likely the collaterals developed as a result of adhesions in the pericardial space. This is a previously unrecognized complication of heart transplantation with potential clinical implications, as coronary to extracardiac artery collaterals have been shown to cause myocardial ischemia.

Clinical experience with 111 thoratec ventricular assist devices.

BACKGROUND: Ventricular assist devices (VADs) have gained wider acceptance due to refinements in patient selection and management and device availability. METHODS: To evaluate early and late results, we reviewed our first 111 patients with the Thoratec VAD. RESULTS: Forty-four patients were supported for myocardial recovery. The mean age in the recovery group was 51.9 years. There were 18 left VADs (LVADs), 17 biventricular VADs (BVADs), and nine right VADs (RVADs). Complications included bleeding in 20 patients (45%) and device-related infection in 1 patient (2%). Nineteen were weaned from the VAD, with 12 survivors. Sixty-seven patients were supported as a bridge to cardiac transplantation. The mean age was 41.5 years. There were 39 LVADs and 28 BVADs. Complications included bleeding in 21 patients (31%) and device-related infection in 12 (18%). Three patients were weaned and 39 patients were transplanted from the assist device, for a total of 42 bridge survivors. Device-related thromboembolism occurred in 9 patients (8.1%), 7 of whom were bridge to transplantation. The duration of VAD support ranged from 0.1 to 27 days (mean 4.5 days) in the recovery group and 0.2 to 184 days (mean 40.7 days) in the bridge to transplantation group. The 10-year actuarial survival was 16% for the recovery group, 22%, for the bridge group, and 33% for transplanted patients. CONCLUSIONS: Despite advances, VAD support remains associated with significant morbidity and operative mortality.

Balloon angioplasty of long-segment aortic coarctation in the neonate.

It is generally believed that balloon angioplasty of diffuse, long-segment aortic coarctation is not effective. In this report, we describe two neonates with diffuse, long-segment coarctation in association with complex congenital heart defects in whom we were successful in effectively treating coarctation with transumbilical artery balloon angioplasty. Based on this experience, it may be concluded that balloon angioplasty of long-segment coarctation in neonates is feasible and effective, but confirmation in a larger group of patients may be necessary prior to general adoption of this concept.

Postoperative junctional ectopic tachycardia.

PURPOSE: To report the management of junctional ectopic tachycardia after cardiac surgery in an infant. Postoperatively, the patient suffered profound cardiac decompensation secondary to the accelerated rhythm and required extracorporeal membrane oxygenation (ECMO) for haemodynamic support. CLINICAL FEATURES: A 14-day-old, 3.5 kg boy exhibited junctional ectopic tachycardia after cardiopulmonary bypass. Left atrial pressure was 25-28 mmHg. No impact on the tachycardia was seen after rapid overdrive atrial pacing or after 20 micrograms fentanyl i.v., 45 micrograms digitalis, 100 mg magnesium or procainamide (loading dose 15 mg, then 30 mg.kg-1.min-1). Active cooling decreased the nasopharyngeal temperature to 35.2 degrees C, when the heart rate decreased below 180 bpm with a left atrial pressure of 8-10 mmHg. Dopamine (2 micrograms.kg-1.min-1) and dobutamine (5 micrograms.kg-1.min-1) were added to improve the cardiac output. Sodium nitroprusside (0.25 to 1 microgram.kg-1.min) maintained the systolic pressure < 100 mmHg. On arrival in ICU, heart rate increased to 200 bpm. The patient received cardiac massage for severe hypotension 75 min after surgery. Emergency ECMO was instituted for circulatory support. Procainamide, digoxin, dopamine, dobutamine, sodium nitroprusside and hypothermia were continued. Sinus rhythm resumed on the first postoperative day, but procainamide and induced hypothermia at 34 degrees C were maintained for 36 hr after normalization of the rhythm to prevent recurrence of the tachycardia. Total duration of ECMO was three and a half days. Recovery was uneventful. CONCLUSION: The use of ECMO, as a first line of defence, is suitable for the emergency support of patients with JET because of the ease of support of circulation and precise control of hypothermia.

Mitral valve replacement: randomized trial of St. Jude and Medtronic Hall prostheses.

BACKGROUND: This study was designed to better define the merits of the bileaflet and tilting-disc valves. METHODS: We prospectively randomized 156 patients (mean age, 59 years) to receive either the St. Jude (n = 80) or the Medtronic Hall (n = 76) mitral valve prosthesis between September 1986 and December 1997. The two groups were not significantly different with respect to preoperative New York Heart Association class, left ventricular ejection fraction, incidence of mitral stenosis or insufficiency, extent of coronary artery disease, completeness of revascularization, or cross-clamp or bypass time. RESULTS: The operative mortality (11.2% versus 13.1%, St. Jude versus Medtronic Hall, respectively) and late mortality (27% versus 22%, St. Jude versus Medtronic Hall, respectively) were not significantly different. Follow-up was complete in all hospital survivors with a mean of 60.7 months (range, 1 to 133 months). The analysis of 10-year actuarial survival and freedom from valve-related events demonstrated no significant differences between the cohorts. Freedom from reoperation was higher in the St. Jude group (p < 0.01). Comparisons of patient functional status and echocardiographic hemodynamic parameters obtained at the time of follow-up demonstrated no significant differences between the two prostheses. CONCLUSIONS: This study suggests that there is no difference between the St. Jude and Medtronic Hall prostheses with respect to late clinical performance or hemodynamic results and therefore does not support the preferential selection of either prosthesis.

Intermittent antegrade tepid versus cold blood cardioplegia in elective myocardial revascularization.

BACKGROUND: The ideal temperature for blood cardioplegia administration remains controversial. METHODS: Fifty-two patients who required elective myocardial revascularization were prospectively randomized to receive intermittent antegrade tepid (29 degrees C; group T, 25 patients) or cold (4 degrees C; group C, 27 patients) blood cardioplegia. RESULTS: The two cohorts were similar with respect to all preoperative and intraoperative variables. The mean septal temperature was higher in group T (T, 29.6 degrees +/- 1.1 degrees C versus 17.5 degrees +/- 3.0 degrees C; p < 0.0001). After reperfusion, group T exhibited significantly greater lactate and acid release despite similar levels of oxygen extraction (p < 0.05). The creatine kinase-MB isoenzyme release was significantly lower in group T (764 +/- 89 versus 1,120 +/- 141 U x h/L; p < 0.04). Hearts protected with tepid cardioplegia demonstrated significantly increased ejection fraction with volume loading, improvement in left ventricular function at 12 hours, and decreased need for postoperative inotropic support (p < 0.05). The frequency of ventricular defibrillation after cross-clamp removal was lower in this cohort (p < 0.05). There were no hospital deaths, and both groups had similar postoperative courses. CONCLUSIONS: Intermittent antegrade tepid blood cardioplegia is a safe and efficacious method of myocardial protection and demonstrates advantages when compared with cold blood cardioplegia in elective myocardial revascularization.

Valve replacement in the small aortic annulus: prospective randomized trial of St. Jude with Medtronic Hall.

OBJECTIVE: The ideal prosthesis for aortic valve replacement in patients with small annuli remains controversial and has yet to be identified. The purpose of this report is to compare the St. Jude (SJ) Medical and Medtronic Hall (MH) valves for aortic valve replacement in the small aortic root. METHODS: From 1986 to 1994 we prospectively randomized 456 patients to receive either the SJ or the MH valve. From this population, 80 patients (SJ, 42 patients; MH 38 patients) had a 19 or 21 mm aortic prosthesis inserted without annulus enlarging procedure. RESULTS: Follow-up was complete in all 80 patients for 270 patient years (mean 40.5 months). Analysis showed that the SJ and MH groups were similar with respect to age, gender, body surface area, valve area, NYHA class, ventricular function, prosthesis size, frequency of revascularization, bypass and global ischemic time. There were two operative deaths (1 SJ, 1 MH). Clinical performance and Dobutamine stress transesophageal doppler echocardiography could not demonstrate a significant advantage of one prosthesis over the other in this population. The change in aortic valve gradient, and left ventricular mass index measured preoperatively and within 12 months postoperatively were not different in both cohorts. CONCLUSION: The study could not detect a difference in the performance of the SJ and MH heart valves for aortic valve replacement in patients with small aortic annuli.

Management of asymptomatic mild aortic stenosis during coronary artery operations.

BACKGROUND: Management of asymptomatic mild aortic stenosis at the time of coronary artery bypass grafting (CABG) remains controversial. We have retrospectively analyzed a cohort of patients requiring aortic valve replacement (AVR) subsequent to CABG and compared their operative morbidity and mortality with that of a group receiving CABG and AVR simultaneously at the first operation. METHODS: Analysis is drawn from 28 patients who required AVR 8 +/- 4 years subsequent to CABG (group A) and 175 patients receiving AVR along with CABG at the primary operation (group B). Groups were similar with respect to age, sex, risk factors for cardiac disease, extent of coronary artery disease, left ventricular function, New York Heart Association class, aortic valve area, number of grafts, and size of prosthesis inserted. RESULTS: Patients having AVR subsequent to CABG had a significantly prolonged aortic cross-clamp time and global myocardial ischemic time and incurred a twofold increase in operative mortality. The actuarial survival at 10 years was not significantly different between cohorts. In the 28 patients in group A, the aortic valve area during the period between operations decreased 0.05 mm2/y. CONCLUSIONS: The operative mortality and morbidity of a second operation for AVR is high, but there is no significant difference in survival at 10 years. In at least a portion of patients having mild aortic stenosis at the time of CABG there will be progression of the stenosis necessitating reoperation at a later date.

Double-valve replacement with Medtronic-Hall or St. Jude valve.

To define better the performance of the bileaflet St. Jude and the tilting-disc Medtronic-Hall valves, we retrospectively analyzed 122 patients (St. Jude, 80 patients; Medtronic-Hall, 42 patients) who received simultaneous aortic and mitral replacement from May 1984 until June 1994. The two groups were not different with respect to preoperative clinical and hemodynamic parameters and New York Heart Association functional class. The hospital mortality and late mortality were not significantly different. Risk analysis identified advanced age and previous myocardial revascularization as predictors of operative death. Follow-up was complete in 96 of 103 hospital survivors (93%) and was similar in both groups. The actuarial survival, linearized rates of valve-related complications, and actuarial freedom from valve-related complications were similar in both cohorts. The presence of coronary artery disease negatively influenced the actuarial survival after simultaneous aortic and mitral valve replacement. Postoperative New York Heart Association functional class was not significantly different in either group. These data indicate that the Medtronic-Hall and St. Jude prostheses are not significantly different with respect to their clinical performance and valve-related complications for simultaneous double-valve replacement.

Tailoring aortoplasty for repair of fusiform ascending aortic aneurysms.

To evaluate the effectiveness of tailoring aortoplasty used to treat fusiform aneurysms of the ascending aorta, we reviewed the results of operation in 17 patients. Nine patients had tailoring aortoplasty alone, and 8 patients had aortoplasty with Dacron wrap of the ascending aorta. Fourteen of 17 patients were discharged from the hospital, and 12 patients were alive at follow-up between 2 and 120 months. Of two late deaths, neither was due to aneurysmal disease. Actuarial survival at 1 and 10 years was 81% and 63%, respectively. In selected cases, tailoring aortoplasty can achieve long-term results comparable with those of resection and graft replacement of fusiform ascending aortic aneurysms.

Prosthetic valves for the small aortic root.

Mechanical aortic valves (AVs) are frequently implanted in small (19 and 21 mm) aortic roots because bioprosthetic valves have unacceptably high gradients and many surgeons do not implant allograft valves. Three mechanical valves in common use today in the United States are the Starr-Edwards (SE), St. Jude Medical (SJ), and the Medtronic-Hall (MH). Clinical hemodynamic studies reveal that the 21-mm SE valve (size 8A) has peak systolic gradients of 13 to 58 mmHg (N = 6) with a calculated effective orifice of 0.7 to 1.4 cm2. The 19-mm SJ valve has a gradient at peak pressure of 17 mmHg and a mean gradient of 22 mmHg (N = 6) with respective exercise gradients of 32 and 38 mmHg (N = 5). For the 21-mm SJ valve the mean gradient was 5.2 +/- 5.3 (N +/- 12) and the gradient at peak pressure was 6.0 mmHg (N = 15). The 21-mm MH valve had resting gradients at peak pressure of 10.5 (N = 3) and 12.4 mmHg (N = 9) and exercise gradients of 15.8 mmHg (N = 9). Six months after AV replacement with small SJ or MH (N = 14) or large (23 mm or greater) (N = 83) valves, cardiac output was 4.7 versus 6.4 L/min (p < 0.03), percent reduction in left ventricular mass index (LVMI) was -8% versus -21% (p < 0.01), exercise duration was 370 versus 555 seconds, and congestive heart failure (CHF) class was 1.9 versus 1.1 (p < 0.0001). Change in LVMI and valve size were the only independent predictors of CHF class.(ABSTRACT TRUNCATED AT 250 WORDS)

Lung cancer surgery in the octogenarian.

From 1981 through 1991, 40 patients 80 years of age or older underwent thoracotomy for curative resection of bronchogenic carcinoma. There were 22 males and 18 females with a mean age of 82.7 years (range 80-88). In three patients, the operation was aborted due to unexpected metastatic disease discovered at the time of thoracotomy. The remaining 37 patients underwent 5 pneumonectomies, 26 lobectomies and 6 segmentectomies or wedge resections. Three of these patients (1 pneumonectomy, 1 lobectomy, and 1 wedge resection) underwent concomitant en bloc chest wall resection. The overall operative mortality rate (in hospital or within 30 days) was 15% (6/40) while there was a 16% mortality rate (6/37) for resected patients. Complications occurred in 18 of 40 patients (45%) but were major in only 12 (30%). Major complications included respiratory insufficiency (6), pneumonia (4), prolonged air leak (2), stroke (1), urinary retention prostatectomy (1), and one unexplained sudden death 2 weeks following discharge. Postoperative stay in the 34 operative survivors averaged 14 +/- 8.8 days (range 3-47). Univariate analysis revealed that neither gender, extent of lung resection, preoperative NYHA class, history of heart disease nor chronic obstructive pulmonary disease (COPD) were predictive of operative mortality in the 37 patients undergoing lung resection. Age was the only predictor of mortality (survivors 82.2 +/- 2.2, non-survivors 84.3 +/- 2.6; P < 0.05). The need for chest wall resection approached but did not quite achieve significance (P < 0.08). Actuarial survival for all 40 patients at 1 and 3 years is 55% and 40%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)