The Sorin Bicarbon valve: clinical evaluation in Israel.

BACKGROUND: Four collaborating centers pooled their results with the Sorin Bicarbon Bileaflet valve. MATERIAL AND METHODS: Between 6/91 and 11/95, 431 patients, 235 males and 196 females, underwent valve replacement using the new Sorin prosthesis; age range: 16-88, mean 61.4 yrs. OPERATIONS: AVR - 206, MVR - 177, TVR - 1, DVR - 47. Additional procedures - 139: CAB -117, valve repair - 22. AV sizes: 19-27, MV sizes: 21-33. RESULTS: Thirty day mortality was 4.3%. Early complications included: CVA - 1.4%, +ve blood culture - 2%, reop for bleeding - 5%. Late complications: infective endocarditis - 2.3%, valve thrombosis - 0.2%, thromboemboli - 2.5%, major bleeding - 1.6%, reoperation - 3%, late deaths (all causes) - 4.3%. No structural deterioration has been reported with this valve and acceptable gradients have been observed. Hemolysis is negligible. CONCLUSIONS: Based on this intermediate experience the Sorin Bicarbon prosthesis is well-designed with good hemodynamic properties, and an acceptably low incidence of complications.

Early experience with the Sorin bileaflet prosthetic valve.

Between 1.6.1991 and 31.5.1995, 62 patients underwent heart valve replacement with Sorin Bicarbon bileaflet prosthetic valve, age 16-83 years (mean 60.5). The valve disease was rheumatic in 37 cases, degenerative in 17, congenital in 4 and miscellaneous etiologies in the other 4. The valve lesion was AS in 24 patients, AR in 5, AR+MS in 2, MS in 13, MR+MS in 6, MR in 6, tricuspid prosthetic stenosis in 1, A+M disease in 3, and a clotted prosthetic valve (Sorin disc) in 1. CAD was present in 14 patients (23%) and AF in 19 (31%). 11 had moderate pulmonary hypertension and 4 severe. Preoperatively 6 patients were in FC II, 40 in FC III and 16 in FC IV. Operative procedures included AVR 18, AVR+CABG 13, AVR+T annuloplasty 1, AVR and open M valvotomy 1, MVR 7, MVR+T annuloplasty 7, MVR+AVR (Medtronic) 1, MVR+AVR 1, TVR, prosthetic valve replacement 1, and MVR+CABG 1. Hospital mortality was 3 (4.8%) -- one due to ruptured A-V groove and two due to LoCO. Postoperative complications: LoCO necessitating IABP -- 3 patient; 3 transient CVA and 1 CVA with hemiplegia. One patient had aortic prosthetic valve endocarditis 18 months following the operation necessitating reoperation. Other cases were treated for positive blood cultures. One patient had CVA after anticoagulant were discontinued. 28 patients are in FC I, 22 in H, 4 in III and 1 in IV. 4 patients are lost to follow-up. These data suggest that the Sorin Bicarbon Prosthetic valve can be safely and effectively used for heart valve replacement.

[Treatment of concomitant coronary and carotid disease].

The optimal surgical treatment for concomitant carotid and coronary artery disease is controversial. Between 1991 and 1995 we performed 34 procedures for combined disease of the carotid and coronary arteries. The first 8 operations were carotid endarterectomies followed by coronary artery bypass grafting (staged procedure). The next 26 operations were performed during a single anesthesia (combined procedure). The patients were 28 men and 6 women, aged 58-81 years (mean 68). 80% were in functional class III or IV. In 40% ventricular function was moderately or severely reduced. There was an average of 3.6 grafts per patient, and in all except 3 patients the left internal thoracic artery was used as a conduit for coronary artery bypass grafting. 30% had symptomatic carotid stenosis; there was no perioperative mortality. In the staged procedure group, 2 patients had postoperative cardiac complications: in 1 acute coronary insufficiency and acute myocardial infarction in the other. 1 had postoperative, transient, amaurosis fugax. In the combined procedure group, 1 had a myocardial infarction and 1 a minor occipital stroke. During follow-up, 1 patient died 4 months after operation of myocardial infarction, and 1 had a minor stroke. The results suggest that the combined procedure is safe and carries low risk of both mortality and morbidity. Whenever cardiac disease is stable and there is no main coronary artery disease, a staged procedure should be considered. In any other situation we continue to perform the combined procedure.

Early experience in lung transplantation.

Lung transplantation is becoming an acceptable mode of therapy worldwide for the end-stage lung disease. We present our initial experience with the first 10 consecutive lung transplant patients at Hadassah University Hospital. There were 5 males and 5 females with an age range 27 to 59 years. Eight patients underwent single lung transplantation, one patient had double lung transplantation and one had heart-lung transplantation. Indications were: pulmonary fibrosis in 4, emphysema in 4, cystic fibrosis in 1, and cystic bronchiectasis in 1. Two patients had primary graft failure (1 death). Nine patients had a serious infection after transplantation (1 death). Four patients developed airway complications including dehiscence of bronchial anastomosis (1 death), bronchial stenosis requiring placement of a stent in 2 patients, and pneumothorax in 1 patient. One patient required tracheostomy. One patient died of massive brain infarction secondary to pulmonary venous thrombosis and embolization. Six patients are intermediate-term survivors, with a follow-up period of 4-24 months. Four of them had at least one episode of rejection each. In all survivors pulmonary functions and quality of life improved and they do not need supplemental oxygen. We conclude that lung transplantation is a viable option for end-stage lung disease. Better selection of patients and perhaps improved immunosuppression agents will further improve outcome in lung transplantation. Shortage of donor supply is currently the limiting factor in successful lung transplantation in Israel.

Warm blood cardioplegia for patients undergoing revascularization for left main coronary artery disease.

Between February 1991 and June 1992, 62 patients (50 males) underwent coronary artery bypass (CAB) operation for significant left main coronary artery disease. Age varied between 47 and 81 years. 53 patients had unstable angina, 16 had recent myocardial infarction, and 16 had heart failure. 22 patients were in functional capacity class IV (Canadian Heart Association) and 2 patients were in unstable hemodynamical condition before the operation. Intraaortic balloon pump was inserted before the operation in 3 patients. Six patients had previous CAB surgery. All the patients were operated using myocardial protection with warm blood cardioplegia, given antegradely and retrogradely in 58 and only antegradely in 4 patients. Body temperature was maintained at 30 +/- 1.8 degrees C. Number of distal anastomoses averaged 4.3 +/- 0.9. One patient underwent additional resection of a left atrial myxoma and another aortic valve replacement. LIMA (left internal mammary artery) was used to bypass the LAD in 58 (94%) patients. Early mortality was 3 cases (4.8%). Major and minor postoperative complications occurred in 17 patients. These data suggest that warm blood cardioplegia provides superior myocardial protection in patients with left main coronary artery disease.

[Gunshot trauma to the common carotid artery].

A case of gunshot trauma to the common carotid artery which presented with a juxtaclavicular pulsating hematoma is presented. After precise diagnosis was established by angiography, reconstruction by interposing and autologous saphenous vein graft was successful. Aspects of this highly lethal type of trauma include the need for close observation of the asymptomatic patient, indications for exploring penetrating neck trauma, the need for routine angiography and reconstructive arterial surgery in the presence of central neurological damage, relevant surgical techniques, and the availability of parasurgical facilities. The current consensus is to perform reconstructive arterial surgery when feasible, regardless of preoperative neurological status. Preoperative angiography is definitely recommended in any hemodynamically stable patient who is not suffocating. An aggressive approach, surgical expertise and perioperative support might reverse the poor prognosis in these otherwise fatal cases.

Obstruction of mechanical heart valve prostheses: clinical aspects and surgical management.

One hundred patients (32 male) aged 5 months to 82 years (median 32 years) underwent 106 surgical procedures for 112 mechanical prosthetic valves obstructed by a thrombus (n = 61) or pannus (n = 7), or both (n = 44), between January 1, 1980 and December 31, 1989. The position of the obstructed prosthesis was aortic in 51 patients (48%), mitral in 49 (46%) and both aortic and mitral in 6 (6%). The types of obstructed prosthetic valves were Björk-Shiley (n = 51), St. Jude (n = 41) and Medtronic-Hall (n = 20). The time interval between valve replacement and obstruction ranged from 6 weeks to 13 years (median 4 years). Of 63% of patients in whom coagulation variables were available at the time of obstruction, 70% were receiving inadequate anticoagulant therapy. In 63% of the procedures the patient was in New York Heart Association functional class IV. Two patients underwent preoperative thrombolysis with incomplete results. Operative procedures included valve replacement (n = 81), valve declotting and excision of pannus (n = 23) and aortic valve replacement and mitral valve declotting (n = 2). The early mortality rate was 12.3% (13 patients), and there was no difference between surgery for mitral prostheses (12.2%) versus aortic prostheses (13.7%). The perioperative mortality rate was 17.5% (11 of 63 patients) in patients in functional class IV and 4.7% (2 of 43 patients) in those in functional classes I to III (p less than 0.05). For valve replacement, the mortality rate was 12% (10 of 81 patients) and for declotting of the prosthesis 13% (3 of 23 patients).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical removal of a mobile, pedunculated left ventricular thrombus: report of 4 cases.

During an 11-month period, 4 patients underwent surgical removal of a mobile, pedunculated left ventricular thrombus. All 4 patients had a history of myocardial infarction. Two of the 4 patients had systemic emboli, and in the 2 others, the ventricular thrombi were removed to prevent emboli. The thrombus was removed during the acute phase of myocardial infarction in 2 patients and one and two years, respectively, following the infarct in the remaining 2 patients. Concomitant coronary artery bypass grafting was performed in 3 patients. There were no early or late deaths, and none of the patients had clinical or echocardiographic evidence of recurrent thrombi or emboli at follow-up 3 to 15 months later. These results indicate that left ventricular thrombectomy might be an effective treatment for patients with mobile, pedunculated, left ventricular thrombi. However, additional experience is required to compare surgical and medical treatment.

A safe and rapid method for the mobilization of the internal mammary pedicle.

A simple method is described for the safe and rapid dissection of the internal mammary pedicle. The essential feature of this technique is the use of Silicone Rubber devices, for the identification and retraction of the internal mammary pedicle during its preparation.

Medial and lateral arcuate ligaments of the diaphragm: attachment to the transverse process.

According to current anatomy textbooks, the diaphragmatic medial and lateral arcuate ligaments are attached to the transverse process of the first lumbar vertebra. In dissections of 15 human cadavers we found both arcuate ligaments attached to the transverse process of L2 (10 cases and L3 (5 cases). In no case were they attached to the transverse process of L1.

Total excision of a giant angiolipoma of chest wall with A-V malformation and with the use of an autotransfusion system.

An 18 year old girl suffering from a giant angiolipoma of back and chest wall with A-V malformation underwent total excision of the tumor in 4 stages. The first two stages included surgical ligation of the arterial blood supply to the tumor. In the third and fourth stages the tumor was resected with the use of an autotransfusion system. The last stage was complicated with massive bleeding and disseminated intravascular clotting. Control of bleeding was achieved by the use of autotransfusion system, right thoracotomy and massive transfusion of blood and its components. After long convalescence period associated with renal and respiratory failure the patient recovered completely without sequellae. This case demonstrates the complexity associated with the treatment of these rare tumors.