St. Thomas' Hospital cardioplegia: enhanced protection with exogenous creatine phosphate.

BACKGROUND: Experimentally, creatine phosphate (CP) improves postischemic recovery of function and reduces postischemic arrhythmias. METHODS: We studied 50 patients undergoing valve replacement. They were randomized into either a control group, who received St. Thomas' Hospital cardioplegic solution No. 1, or a CP-treated group, receiving the same cardioplegic solution plus CP (10 mmol/L). There were no preoperative clinical differences between groups. Assessment was by electrocardiographic analysis, inotropic drug requirement, quantitative birefringence, myocardial high-energy phosphate content, function, and semiquantitative ultrastructural assessment. RESULTS: Direct-current shocks were reduced in the CP-treated group (0.88 +/- 0.15) compared with the control group (1.40 +/- 0.14; p < 0.02), as was the total number of joules (22.0 +/- 3.5 versus 34.4 +/- 3.7, respectively; p <0.02). The incidence of spontaneous sinus rhythm was higher in the CP-treated group (40% versus 8%; p < 0.05) and the incidence of postoperative arrhythmias, lower (8% versus 32%; p < 0.05). Prolonged inotropic administration (12 hours or longer) occurred in fewer patients in the CP-treated group (4% versus 28%; p < 0.05). Response to inotropic support (in the subset of patients requiring this treatment) was significantly greater in the CP-treated group than in the control group. There were no differences in recovery of function, birefringence changes, myocardial high-energy phosphate content, or ultrastructure between groups. CONCLUSIONS: St. Thomas' Hospital cardioplegic solution No. 1 plus CP enhanced myocardial protection and conferred a direct benefit to the patient by reducing postoperative arrhythmias and need of prolonged inotropic support.

Aortic valve replacement with the Jyros bileaflet prosthetic valve; early echocardiographic and radiological evaluation.

The Jyros bileaflet prosthetic heart valve has a unique hinge mechanism permitting rotation of the leaflets within the valve ring. Thirty patients undergoing aortic valve replacement with a Jyros valve were assessed clinically, echocardiographically and radiologically. Rotation of the valve in vivo was assessed, as well as the hemodynamic characteristics of the valve at rest and after exercise, and functional capacity of the valve recipients. Measured transvalvar gradients were comparable with other bileaflet valves at rest and after exercise, as were calculated effective orifice areas. Initially only four prostheses (13%) showed any evidence of rotating, but this improved to 14 of 23 investigated (60.9%) after exercise; rotation appears to be more common in smaller valves. There were no operative or early deaths, but one patient died at 11 months from a type A ascending aortic dissection. During a total of 28.5 patient-years of follow up (range 2-24 months) valve related complication has not been reported. All survivors are in good clinical condition. Preliminary results with the Jyros valve compare well with other bileaflet devices for aortic valve replacement; the hemodynamic performance of the valve does not appear to be affected by rotation or non-rotation.

A clinical comparative study between crystalloid and blood-based St Thomas' hospital cardioplegic solution.

OBJECTIVE: Myocardial protection with blood cardioplegia during cardiac surgery is increasingly preferred, but few studies have compared the protective effects of crystalloid cardioplegia to the same solution with blood as the only variable. This clinical study compared the protective effects of crystalloid or blood-based St. Thomas' Hospital cardioplegic solution No. 1. METHODS: Fifty higher risk patients undergoing elective coronary artery bypass surgery, with an ejection fraction less than 40%, were randomly allocated to receive cold (4 degrees C) intermittent crystalloid St. Thomas' No. 1 cardioplegia (n = 25), or a similar blood-based solution (n = 25) with a haematocrit of 10-12%. We determined (1) peri-operative and post-operative arrhythmias, (2) left and right ventricular function (24 h) using the thermodilution technique, (3) left ventricular high-energy phosphate content sampled before ischaemia, the end of ischaemia and the end of bypass. RESULTS: Pre-operative haemodynamic data, aortic cross-clamp and bypass times were similar in both groups of patients; there was no mortality. At the end of ischaemia there were no differences in ATP content between groups but creatine phosphate was maintained at a significantly (P < 0.007) higher level in the blood-based St. Thomas' cardioplegia group than the crystalloid St. Thomas' cardioplegia group (20+/-2 (SE) vs. 13+/-1 micromol/g dry wt, respectively). Return to spontaneous sinus rhythm was significantly (P = 0.002) increased in the blood-based St. Thomas' cardioplegia group (96%) compared to the crystalloid St. Thomas' cardioplegia group (60%). Early post-operative ventricular dysfunction occurred in both groups, but normal LV function (stroke work index) recovered significantly (P = 0.043) more rapidly (by 2 h) in the blood-based St. Thomas' cardioplegia group of patients. CONCLUSIONS: In a higher risk (EF < 40%) group of patients undergoing elective cardiac surgery, addition of blood to an established crystalloid cardioplegic solution significantly enhanced myocardial protection by reducing arrhythmias, improving rate of recovery of function and maintaining myocardial high-energy phosphate content during ischaemia.

Impact of preprocedural mitral regurgitation upon mortality after transcatheter aortic valve implantation (TAVI) for severe aortic stenosis.

OBJECTIVE: To identify the effects of preprocedural significant mitral regurgitation (MR) and change in MR severity upon mortality after transcatheter aortic valve implantation (TAVI) using the Edwards SAPIEN system. METHODS: A retrospective analysis of 316 consecutive patients undergoing TAVI for aortic stenosis at a single centre in the UK between March 2008 and January 2013. Patients were stratified into two groups according to severity of MR: ≥grade 3 were classed as significant and ≤grade 2 were non-significant. Change in MR severity was assessed by comparison of baseline and 30-day echocardiograms. RESULTS: 60 patients had significant MR prior to TAVI (19.0%). These patients were of higher perioperative risk (logistic EuroScore 28.7±16.6% vs 20.3±10.7%, p=0.004) and were more dyspnoeic (New York Heart Association class IV 20.0% vs 7.4%, p=0.014). Patients with significant preprocedural MR displayed greater 12-month and cumulative mortality (28.3% vs 20.2%, log-rank p=0.024). Significant MR was independently associated with mortality (HR 4.94 (95% CI 2.07 to 11.8), p<0.001). Of the 60 patients with significant MR only 47.1% had grade 3-4 MR at 30 days (p<0.001). Patients in whom MR improved had lower mortality than those in whom it deteriorated (log-rank p=0.05). CONCLUSIONS: Significant MR is frequently seen in patients undergoing TAVI and is independently associated with increased all-cause mortality. Yet almost half also exhibit significant improvements in MR severity. Those who improve have better outcomes, and future work could focus upon identifying factors independently associated with such an improvement.

Hybrid repair of complex thoracic aortic arch pathology: long-term outcomes of extra-anatomic bypass grafting of the supra-aortic trunk.

PURPOSE: Hybrid repair constitutes supra-aortic debranching before thoracic endovascular aortic repair (TEVAR). It offers improved short-term outcome compared with open surgery; however, longer-term studies are required to assess patient outcomes and patency of the extra-anatomic bypass grafts. METHODS: A prospectively maintained database of 380 elective and urgent patients who had undergone TEVAR (1997-2011) was analyzed retrospectively. Fifty-one patients (34 males; 17 females) underwent hybrid repair. Median age was 71 (range, 18-90) years with mean follow-up of 15 (range, 0-61) months. RESULTS: Perioperative complications included death: 10 % (5/51), stroke: 12 % (6/51), paraplegia: 6 % (3/51), endoleak: 16 % (8/51), rupture: 4 % (2/51), upper-limb ischemia: 2 % (1/51), bypass graft occlusion: 4 % (2/51), and cardiopulmonary complications in 14 % (7/51). Three patients (6 %) required emergency intervention for retrograde dissection: (2 aortic root repairs; 2 innominate stents). Early reintervention was performed for type 1 endoleak in two patients (2 proximal cuff extensions). One patient underwent innominate stenting and revision of their bypass for symptomatic restenosis. At 48 months, survival was 73 %. Endoleak was detected in three (6 %) patients (type 1 = 2; type 2 = 1) requiring debranching with proximal stent graft (n = 2) and proximal extension cuff (n = 1). One patient had a fatal rupture of a mycotic aneurysm and two arch aneurysms expanded. No bypass graft occluded after the perioperative period. CONCLUSIONS: Hybrid operations to treat aortic arch disease can be performed with results comparable to open surgery. The longer-term outcomes demonstrate low rates of reintervention and high rates of graft patency.

Blunt traumatic rupture of the thoracic oesophagus.

A man with a crush injury of his upper abdomen developed bilateral pulmonary empyema after repair of tears of the oesophagus and liver. Attempts to withdraw chest drains led to recurrent septicaemia, treated by reinsertion of the drains plus administration of antibiotics. The communication of the empyema space with both the bronchial tree and the oesophagus was managed successfully with intermittent positive pressure ventilation and with a double lumen endobronchial tube isolating the right lung for 10 days. Traumatic rupture of the thoracic oesophagus carries a high mortality and prompt repair is vital.

An unusual cause of ventricular tachycardia.

Inflammatory pseudotumour (IP) of the heart is an extremely uncommon and potentially fatal lesion which presents a challenging diagnosis even for the experienced pathologist, cardiologist and cardiac surgeon. This spindle cell tumour is known to be present in virtually every anatomical region but, in adults, has only previously been found in the heart at postmortem. We report the case of a 27-year-old man who presented with ventricular tachyarrhythmias and a right ventricular mass which was subsequently shown to be an IP.

Adult respiratory distress syndrome following closure of a chronic ventricular septal defect: possible relationship to the use of intracardiac gelatin-resorcin-formaldehyde glue.

Gelatin-resorcin-formaldehyde glue is now widely used in cardiac surgery, particularly in Europe. A case is reported where its use may have contributed to the pulmonary dysfunction seen postoperatively after elective closure of a postinfarct ventricular septal defect. It is believed that this is a result of a relatively high exposure of the pulmonary circulation to the glue, in particular to formalin. Although not proven, the authors advise caution when using the glue within the cardiac chambers.

Pollution by halogenated aromatic compounds at Trissino: A case study of groundwater contamination and rehabilitation.

An investigation is presented on industrial contamination by benzotrifluoride percolation into ground water used for drinking water, in a populated area of 20 km(2) at Trissino, north Italy, due to improper chemical waste disposal. Hydrogeological features of the situation are reported, as well as the emergency action taken, such as the surveys made and their analytical results. The epidemiology of the emergency is examined and rehabilitation measures are presented and discussed. Fortunately no major ecological or social disaster occurred, In part thanks to the speed and efficiency with which the affair was handled. It is notable that the authorities kept the public duly informed and thus retained their confidence.

Perforation of the right ventricle by a suction drain.

Suction drains can be used as alternatives to conventional underwater seal drains following cardiac surgery, and may be advantageous under some circumstances. The authors present a case where a suction drain eroded into the right ventricle causing near-fatal haemorrhage following coronary artery surgery. Caution should be exercised in taking the decision to use suction drains, the material from which they are manufactured should be chosen carefully, and close attention paid to their positioning within the mediastinum.

Differential patterns of neutrophil adhesion molecules during cardiopulmonary bypass in humans.

BACKGROUND: Neutrophils are activated during cardiopulmonary bypass, and it is believed that they play an important role in the postoperative inflammatory response. The effects of neutrophils are mediated by the surface adhesion molecules L-selectin, beta 2-integrins, and platelet-endothelial cell adhesion molecule-1 (PECAM-1), and it has been reported that beta 2-integrins are upregulated and L-selectin downregulated by cardiopulmonary bypass. However, the time course of these changes and their relative importance are unclear. METHODS AND RESULTS: To investigate the temporal changes in the expression of the neutrophil surface adhesion molecules L-selectin, beta 2-integrins, and PECAM-1 induced by cardiopulmonary bypass, we used immunofluorescent flow cytometry in blood samples obtained at various times (before anesthesia, before bypass, and 0.25, 0.5, 1, 2, 4, 24, and 48 hours after initiation of bypass) from patients undergoing routine coronary artery bypass graft surgery. Anesthesia had no effect on the expression of any of the study molecules. The expression of all beta 2-integrins was not significantly affected during the entire study period. The mean fluorescence (expressed as a percentage of control) of CD18 did not change significantly during the first 2 hours after the initiation of cardiopulmonary bypass, but then it declined by 4 hours (P = NS) and attained its lowest values after 24 and 48 hours. The mean fluorescence of CD11b and CD11c decreased by 2 and 4 hours and remained reduced after 24 hours and 48 hours. The expression of PECAM-I decreased rapidly after the initiation of cardiopulmonary bypass to achieve 60 +/- 8% of the preanesthesia control values (P < .05) after only 1 hour; it fell to its lowest after 4 hours (44 +/- 8%; P < .05); and then it recovered partially by 24 hours (60 +/- 11%; P < .05), with a further recovery toward control after 48 hours (77 +/- 8%; P = NS). The profile for the mean fluorescence of PECAM-I was identical to that observed with its expression. In contrast, the expression and mean fluorescence of L-selectin were not changed during the 48-hour period. CONCLUSIONS: This study has demonstrated that cardiopulmonary bypass in humans induces (1) a rapid reduction in the expression of PECAM-I of circulating neutrophils, (2) a later reduction of beta 2-intergrin activity without significant changes in their expression, and (3) no alterations in the expression and activity of L-selectin. Thus, although the mechanism for the absence of neutrophil upregulation of beta 2-integrins and downregulation of L-selectin (no activation) remains to be elucidated, the downregulation of PECAM-1 indicates an early neutrophil activation, and its inhibition may represent a target for reducing the inflammatory response usually associated with cardiopulmonary bypass.