Durability of emergency coronary artery bypass for complications of failed angioplasty.

Although emergency coronary artery bypass for complications of percutaneous transluminal coronary angioplasty (PTCA) has proved to be a relatively successful 'bail-out' procedure, little is known about the durability of revascularization under these potentially disastrous circumstances. The authors therefore retrospectively examined their results with this procedure. Emergency coronary artery bypass for complications of PTCA was performed in 112 patients between 1 January 1984 and 19 May 1992. Fifteen patients underwent PTCA for acute myocardial infarction. Eleven patients (9.8%) were stable, and underwent emergency coronary artery bypass after PTCA because of suboptimal angiographic results from percutaneous transluminal coronary angioplasty. None of these stable patients died. The remainder of the patients underwent emergency coronary artery bypass after PTCA because of ongoing documented ischemia, including cardiac arrest requiring cardiopulmonary resuscitation during transit to the operating room in 11 patients (9.8%) and preoperative intra-aortic counterpulsation in 24 (21.4%). The average number of coronary arteries bypassed at emergency coronary artery bypass was 2.2, and 19 patients (17%) received at least one mammary artery conduit. The perioperative incidence of myocardial infarction was 8.9% (10/112), and the operative mortality rate 8% (9/112). During follow-up, which averaged 55 months, the survival rate (including operative mortality) was 85% while 98% of patients experienced freedom from reoperative coronary bypass, 89% experienced freedom from myocardial infarction (including postoperative) and 90% experienced freedom from subsequent catheterization or PTCA. In conclusion, emergency coronary artery bypass for PTCA complications successfully avoids subsequent untoward cardiac events. When compared with published results of PTCA without emergency coronary artery bypass, emergency coronary bypass is more reliable for avoiding subsequent cardiac catheterization (with or without PTCA) than PTCA alone.

Clinical heparin coated cardiopulmonary bypass: reduction of systemic heparin requirements for redo cardiac surgery.

The authors compared blood loss, transfusion requirements, and heparin doses for reoperative cardiac surgery using either: a) a Duraflow (Baxter Corporation, Irvine, CA) heparin coated cardiopulmonary bypass (CPB) system or b) standard CPB. Twenty patients underwent redo cardiac surgery while supported with heparin coated CPB, and 17 patients underwent redo cardiac surgery with standard CPB. The following data are presented as mean +/- standard deviation. The heparin coated CPB circuit group received significantly less heparin than the standard CPB group (322 +/- 80 IU/kg versus 448 +/- 80 IU/kg, p < 0.01). There was no difference in blood loss in the first 24 postoperative hrs or mean transfusion requirements for the two groups. Despite the reduced dose of heparin, the mean activated clotting time in the heparin coated group was similar to the mean activated clotting time of the standard CPB group (577 +/- 98 sec versus 612 +/- 117 sec, p = ns). In conclusion, heparin coated CPB without reduced activated clotting time does not reduce transfusion requirements or blood loss in reoperative cardiac surgery. The heparin coated CPB system allows maintenance of the activated clotting time level despite reduced heparin doses.

Prophylaxis of heart transplant rejection with either antithymocyte globulin-, Minnesota antilymphocyte globulin-, or an OKT3-based protocol.

We compared an equine antithymocyte globulin (ATGAM)-based protocol with a Minnesota antilymphocyte globulin (MALG)-based protocol and a murine monoclonal CD-3 (OKT-)-based protocol in 3 groups of heart transplant (HT) recipients. Thirty-four recipients received a four-day course of ATGAM. Thirty HT recipients received a 14-day course of OKT3. Fifteen HT recipients received MALG for an average of 10 days. The ATGAM group received cyclosporine beginning preoperatively, while the OKT3 and MALG groups received CyA beginning on post-transplant day 4. All three groups received identical azathioprine and similar steroid therapy. The 3 groups were similar in age, donor/recipient HLA mismatches, and donor/recipient gender mismatches. The MALG and OKT3 groups had 20% and 17% females, respectively, while the ATG group had 41% (p < 0.05). Average follow-up exceeded 14 months for each group. The ATGAM group received a higher dose of CyA during "induction" therapy than the OKT3 and MALG groups, and experienced a greater rise in post-transplant serum creatinine levels. We found no difference between the 3 groups in: preoperative creatinine levels, one-year post-transplant creatinine levels, number of patients who could be successfully "weaned" from steroids, or one-year survival. Other data are tabulated as episodes/patient: [table: see text] We conclude that ATG plus preoperative CyA is superior for rejection prophylaxis following heart transplantation when compared with either MALG plus postoperative CyA or OKT3 plus postoperative CyA.

Cardiac isoenzymes following heart transplantation.

Creatine phosphokinase (CPK) isoenzymes are commonly obtained after heart transplantation (HT) to assess myocardial injury of the donor heart. This investigation retrospectively evaluated the utility of this practice. Fifty-six recipients of orthotopic heart transplants had at least two daily CPK-MB studies following HT. All patients were followed up for at least one year (or until death). Nineteen patients had entirely negative CPK-MB determinations (NEG). Eighteen patients had a single positive CPK-MB determination, and were considered to be equivocal (EQUIV). Nineteen patients had more than one daily positive CPK-MB determination (POS). To evaluate the influence of positive CPK-MB determinations on the outcome of HT, we compared the results in the NEG and POS groups. There was no difference in the donor organ ischemic times between the two groups. The duration of follow-up for the two groups was also similar (1,192 days vs 1,020 days). The NEG and POS groups had no significant difference in: 1 year survival (84 percent vs 74 percent); freedom from treated rejection episodes in 3 months (39 percent vs 42 percent); and freedom from coronary artery disease (CAD) at 3 years (83 percent vs 86 percent). Additionally, the ejection fractions of the donor hearts were similar at 1 year post-transplant for the 2 groups (64 percent vs 59 percent). We conclude that myocardial injury, as reflected by post-transplant CPK-MB levels, does not predict one-year mortality, predisposition to rejection, predisposition to coronary artery disease, or ultimate graft dysfunction. In an effort to perform HT more economically, we no longer obtain CPK-MB levels following HT.

Endarterectomy, vein patch, and mammary bypass of the anterior descending artery.

Occasionally the left anterior descending (LAD) coronary artery contains such diffuse calcific atherosclerosis that an area suitable for distal anastomosis with the internal mammary artery (IMA) cannot be found. Additionally, the LAD of some patients contains multiple areas of stenosis, which would prevent free outflow from the IMA graft. In these cases the potentially increased operative risk of LAD endarterectomy is justified to avoid leaving poorly revascularized areas of anteroseptal heart. In an effort to provide the long-term patency benefits of IMA grafting for these patients without the technical difficulty of a lengthy IMA to LAD anastomosis, we have combined saphenous vein patch reconstruction with IMA bypass when LAD endarterectomy is required.

Cardiac transplantation in patients with preexisting malignancies.

A history of preexisting malignancy has been considered a contraindication to cardiac transplantation. The reasons for this prejudice include concerns about potentially deficient intrinsic immunomodulation and fear of cancer recurrence (or development of second cancers) because of therapeutic immunosuppression. In the past four years at the Northern Indiana Heart Institute seven patients with preexisting malignancies underwent cardiac transplantation. Their two-year survival rate was 100%, which is comparable to a rate of 81% in non-malignancy patients. After an average 31 months of follow-up (range = 6-56 months), only one patient has had a recurrent tumor (basal cell carcinoma). Statistical comparison of immunosuppression dosages, incidences of rejection, and incidences of infections between patients with preexisting malignancy and those without preexisting malignancy was performed. We found that the only significant difference was an increased number of infections in preexisting malignancy patients. Additionally, we found no difference in the incidence of posttransplant coronary artery disease in the preexisting malignancy group when compared with those patients without preexisting malignancies. This study demonstrates that patients who have been successfully treated for malignancies have no greater incidence of rejection than those patients without preexisting malignancy. Furthermore, preexisting malignancy patients require no significant modulation of immunosuppression. Although preexisting malignancy patients have a higher incidence of infections than patients without preexisting malignancy, their two-year survival is not worse than the patients without preexisting malignancy.

Cardiac transplantation: first-year experience in a community hospital.

The issue of decentralizing heart transplant services, formerly restricted to a few large medical centers, is currently under review by federal and state governments. We present the results of the first year of cardiac transplantation at a 385-bed community hospital. Twelve patients were selected according to generally accepted criteria from a pool of 24 referrals, all from within 75 miles of our institution. All patients were in New York Heart Association Class IV preoperatively. The one-year survival rate was found to be 82%, which is equivalent to that reported by established centers. All surviving patients were fully rehabilitated. Rates of infection and rejection were lower than expected, and costs were about half the national average. This series, in all likelihood, tests the limits to which the decentralization of cardiac transplant services can be taken. We conclude that cardiac transplantation can be accomplished at a community hospital with results, even for the first patients undergoing transplantation, comparable to those obtained by established programs at major medical centers.

Scalene node biopsy in pulmonary carcinoma: when is it indicated?

While there is universal agreement that palpable scalene lymph nodes should be biopsied in the preoperative evaluation of patients with carcinoma of the lung, the role of biopsy of nonpalpable scalene nodes remains unclear. This report evaluates the results of biopsy of nonpalpable scalene lymph nodes in 101 consecutive patients with bronchogenic carcinoma otherwise deemed candidates for pulmonary resection. The overall incidence of biopsy positive for metastatic disease was 8.9%. No patient with a peripheral primary lesion, regardless of size or cell type, had metastasis to scalene nodes. Six of 15 patients with centrally located adenocarcinomas showed scalene node metastasis, while only 1 of 40 patients with central squamous cell carcinomas had a positive scalene biopsy. Bilateral biopsy was no more likely to yield positive information than ipsilateral biopsy alone. We now recommend preoperative biopsy of nonpalpable scalene nodes only in patients with central lesions in whom the cell type is adenocarcinoma or unknown.

Immediate postoperative digitalization in the prophylaxis of supraventricular arrhythmias following coronary artery bypass.

Regimens of acute preoperative digitalization have been evaluated previously in the prophylaxis of supraventricular tachycardias (SVT) following coronary artery bypass operations, with equivocal results. This study assesses the effectiveness of immediate postoperative digitalization on the incidence of arrhythmias in 407 consecutive patients recovering from myocardial revascularization. In 137 patients treated by our regimen, which begins digitalization within 4 hours postoperatively, the incidence of supraventricular tachyarrhythmias was 2%, while the corresponding figure for 270 untreated patients was 15%. Digitalization reduced the incidence of supraventricular arrhythmias significantly (p less than 0.01), whereas death, ventricular ectopy, and infarction rates were similar in the two groups. The few patients who did have supraventricular arrhythmias while receiving prophylactic digoxin were no more easily treated than patients in the undigitalized group. The timing of administration of digoxin for SVT prophylaxis may be more important than previously recognized. Immediately postoperative digitalization, theoretically preferable to preoperative regimens, is a safe, effective way to reduce the incidence of supraventricular arrhythmias following myocardial revascularization.

Gastroesophageal reflux in infants and children. Diagnosis and management.

Eighty-three infants and children underwent surgical correction of gastroesophageal reflux (GER) from 1973 to 1978. Fifty-four patients had coexistent brain damage (most commonly due to cerebral palsy), eight were previously treated for esophageal atresia, and four had gastroschisis or omphalocele repair. Clinical presentation included failure to thrive in 64 patients, vomiting in 59, and recurrent bouts of aspiration pneumonitis in 43. Barium roentgenography showed GER in 61 patients, whereas additional tests (particularly pH monitoring) were required for detection of GER in 22 patients. After failure of medical management, transabdominal Nissen fundoplication was performed in 80 cases and a Hill repair in three cases. The surgical mortality was zero, but there were five late deaths. Results were considered excellent in 54 patients, good in 22 patients, and poor in seven. Ten of 12 patients with preoperative stricture responded to dilation after fundoplication. Nissen fundoplication was a safe and effective antireflux procedure in 76 of the 83 cases.