Modified Bentall technique for aortic root replacement: a simplified approach to the short left coronary artery.

The short left coronary artery encountered during aortic root replacement with the modified Bentall (coronary button) technique may pose a significant problem for the surgeon. A simple solution entails the placement of a short interposition Dacron graft between the native coronary artery and the aortic graft. This approach has been successfully employed in 2 patients.

Aortic dissection and use of the nicotine patch: a case involving a temporal relationship.

A 33-year-old woman presented with chest and abdominal pain shortly after first and second applications of the nicotine patch. Type A aortic dissection was diagnosed and repaired. Pathological examination revealed cystic medial necrosis, subacute and acute dissection, with no evidence of chronic aortic insufficiency. The close temporal relationship between applications of the nicotine patch and onset of symptoms compatible with dissection followed by extension raises the possibility that the nicotine patch was implicated in, or precipitated, this woman's aortic dissection.

Salvage of ischemic myocardium by nonsynchronized retroperfusion in the pig.

Salvage of ischemic myocardium, with the aid of a nonsynchronized coronary sinus retroperfusion system, was studied in a pig infarct model. In anesthetized open chested animals, the left anterior descending coronary artery was occluded for 4 hours and then reperfused for 1 hour before the animals were killed. In the control group (n = 12) no therapy was used. In the experimental group (n = 13), nonsynchronized retrovenous coronary sinus perfusion was applied during the 4 hours of coronary artery occlusion. Therapy consisted of intermittent balloon occlusion of the coronary sinus (5-second inflation, 5-second deflation) with retroperfusion of arterial blood at 60 ml/min during the inflation part of the cycle. Infarct size, expressed as a percentage of the area at risk (+/- standard deviation), was significantly smaller in the experimental group (41.5% +/- 15.0%) than in the control group (80.5% +/- 6.1%) (p less than 0.001). Mean coronary sinus pressure (+/- standard deviation) was 51 +/- 12 mm Hg in the experimental group but was not elevated in the control animals. We conclude that nonsynchronized retrovenous coronary sinus perfusion was able to significantly salvage ischemic myocardium in a model of minimal intercoronary collateral circulation.

Reconstruction of the left ventricle with autologous pericardium.

Autologous pericardium was used to reconstruct different parts of the left ventricle in 25 desperately ill patients. Fourteen patients had intractable sepsis resulting from infective endocarditis and myocardial abscess and 10 patients had noninfectious disorders. Of the patients with infections, 12 had valvular endocarditis with periannular abscess and three had interventricular septal abscess. The noninfected patients had acute rupture of the ventricular wall after mitral valve replacement (one patient) heavily calcified or surgically absent mitral anulus (three patients), or rupture of the interventricular septum after acute myocardial infarction (six patients). The interventricular septum, the posterior wall of the left ventricle, and the periannular areas were reconstructed by suturing appropriately tailored pericardial patches directly to the endocardium. In patients who also required valve replacement, the prosthetic valve was partially or completely secured to the pericardial patch. There were three operative deaths. All three patients were in either septic or cardiogenic shock before operation and in none of them was the death related to the pericardial patch. All 22 survivors have been observed from 3 to 34 months, an average of 14 months. There has been no case of patch dehiscence, patch aneurysm, prosthetic valve dehiscence, or recurrent endocarditis. Autologous pericardium appears to be safe for reconstruction of the left ventricle. It is easy to handle and problems with suture line bleeding are practically nonexistent.

Ascending aorta to bifemoral bypass--a ventral aorta.

In the decade since April 1975 we accumulated a series of 18 patients with arterial conduits from the ascending aorta to the femoral arteries, 10 men aged 53 to 75 years (mean, 60 years) and eight women aged 33 to 56 years (mean, 50 years). In the first two patients, the conduit was placed subcutaneously; in the remaining 16 patients, it was placed behind the rectus muscle and in front of the posterior rectus fascia, thus following the ventral anastomotic axis of the internal mammary and inferior epigastric arteries. The conduit is not visible, palpable, or compressible in this position. This approach was usually chosen because of multiple failures of standard intra-abdominal and axillofemoral vascular reconstructions. Five patients had concurrent intramediastinal procedures, mostly coronary bypass or innominate artery repair. The early operations were performed with Dacron grafts with a bifurcation constructed just below the umbilicus. In the last nine patients, we have used an 8 or 10 mm polytetrafluoroethylene (PTFE) prosthesis and connected it to a 6 or 8 mm PTFE crossfemoral bypass. No operative deaths occurred. The 5-year patency rate by life-table analysis is 70%. This operation is an alternative to axillofemoral bypass in patients with an inoperable abdominal aortic aneurysm.