Uniformity of perfusion in all regions of the human heart by warm continuous retrograde cardioplegia.

BACKGROUND: Animal models have suggested that retrograde cardioplegia may be poorly distributed to septal and right ventricular regions of the heart; if true, this may have dangerous implications for warm continuous retrograde cardioplegia in humans. We have previously shown that blood gases from coronary arteries during warm continuous retrograde cardioplegia represent postcapillary "venous" gases and are reflective of myocardial perfusion. METHODS: To determine regional differences in perfusion during warm continuous retrograde cardioplegia we obtained blood gases from three regions of the heart in 141 consecutive patients undergoing coronary artery bypass grafting, aortic valve replacement, or both. Right heart perfusion was determined by blood gases from the right coronary artery orifice, acute marginal, or posterior descending coronary arteries; circumflex or lateral wall perfusion was determined by samples from obtuse marginal or intermediate coronary arteries; and anterior wall/septal perfusion was determined by left anterior descending and diagonal coronary artery blood gases. Warm continuous retrograde cardioplegia flow ranged from 150 to 300 mL/min depending on heart size. A mean of 4 +/- 1 samples/patient were obtained. RESULTS: There were no regional differences in postcapillary pH, carbon dioxide tension, or CO2 production during warm continuous retrograde cardioplegia. Oxygen tensions were lower in the right and anterior/septal regions of the heart, implying more O2 uptake. No regional acidosis, consistent with poor perfusion, could be detected. CONCLUSIONS: We conclude that, unlike experimental models, regional myocardial perfusion, including the right heart, is uniform during "high-flow" warm continuous retrograde cardioplegia in humans.

One-stage primary repair of distal esophageal perforation using fundic wrap.

Esophageal leak following primary repair of esophageal perforation is a serious complication that can lead to severe mediastinitis and sepsis. Complete diversion with esophageal exclusion or resection is designed to minimize further mediastinal contamination. However, this approach is not necessarily associated with less morbidity or mortality. Furthermore, a second stage operation is required to restore esophageal continuity. From 1986 to 1994, we performed a one-stage primary repair of the distal esophagus in seven patients with either iatrogenic (n = 5) or spontaneous (n = 2) perforations and reinforced the repair by a fundic wrap. One patient underwent an additional modified Heller myotomy for achalasia. Delay between perforation and operation was less than 6 hours in 3 patients, 6 to 24 hours in 2 patients, and greater than 24 hours in 2 patients. Only one patient (14%) developed a small esophageal leak that spontaneously resolved with adequate mediastinal drainage, intravenous antibiotics, and aggressive nutritional support. One patient (14%), whose repair was delayed by 12 hours, died postoperatively of profound sepsis. This patient was moribund from sepsis preoperatively, and postmortem examination of the esophagus revealed no evidence of esophageal leak. Esophageal continuity was maintained in all patients. The median length of stay was 21 days (range, 15-58 days). We conclude that primary reinforced repair of esophageal perforation using a fundic wrap is an effective method of treatment for distal esophageal perforation, even when the repair is delayed by more than 24 hours.

Pseudoaneurysms of the aorta after cardiac surgery or chest trauma.

Between March 1982 and June 1992, 17 patients (age: 21-76 years) were diagnosed with pseudoaneurysm of the thoracic aorta (PTA). Four PTAs developed post-trauma while 13 developed after aortic or cardiac surgery. Unusual presentations included: dyspnea, hoarseness, dysphagia, massive hemoptysis (2 degrees to aortobronchial fistula), massive hematemesis (2 degrees to aorto-esophageal fistula), superior vena cava syndrome, paralyzed right hemidiaphragm, and herald bleeding from the sternotomy. The interval between initial operation and recognition of PTA varied from three months to eight years while the four posttraumatic PTAs presented 5 to 26 years postinjury. The sites of postoperative PTA were: the aortotomy (3), proximal vein graft anastomosis (4), aortic cannulation site (2), and distal anastomosis of ascending aortic graft replacement (4). Aortography was very sensitive, outlining the false aneurysm in 13/13. Five patients had transesophageal echo-cardiography with one false negative. Seven patients died (41%), three from postoperative PTAs from massive hemorrhage intraoperatively and four from sepsis and multiorgan failure following repair. We conclude that patients who have previously had aortic or cardiac surgery or a history of blunt chest trauma presenting with unusual cardiorespiratory symptoms should be aggressively evaluated for PTA. Due to the magnitude of the operative problems encountered, repair of PTA is associated with a significantly high rate of mortality.

Bless the babies: one hundred fifteen late survivors of heart transplantation during the first year of life. The Loma Linda University Pediatric Heart Transplant Group.

There is a rapid growth of interest in heart transplantation therapy during early infancy. From 10% to 25% of the infants who are listed for transplantation annually have died while awaiting a donor heart. There has been no significant trend in this variable. Since November 1985, 140 consecutive orthotopic transplantation procedures were performed in 139 infants who were from 3 hours to 12 months of age. Indications for transplantation included hypoplastic left heart syndrome (63%), other complex structural anomalies (29%), myopathy (6.5%), and tumors (1.5%). Most recipients had ductus-dependent circulation and received continuous infusion of prostaglandin E1. Heart donors were usually victims of trauma, sudden infant death, or birth asphyxia. A donor-recipient weight ratio of 4.0 or less was found to be acceptable. The amount of time the graft underwent cold ischemia, ranged from 64 to 576 minutes. The procurement process was facilitated by a single dose of cold crystalloid cardioplegic solution and cold immersion transport. Profound hypothermic circulatory arrest was used for graft implantation. One hundred twenty-four (89%) recipients survived transplantation and were discharged from the hospital. There were 9 late deaths, which resulted in an 83% overall survival. The 5-year actuarial survival is 80%. The survival among newborn recipients (n = 60) at 5 years is 84%. Chronic immunomodulation was cyclosporine-based and steroid-free. Surveillance was noninvasive and relied heavily on echocardiography, electrocardiography, and clinical intuition. There was one documented late lethal infection, tumor was not encountered, and coronary occlusive disease was known to exist in only one long-term survivor. We concluded that transplantation results in excellent life quality and is a highly effective and durable therapy when applied during early infancy.

Thrombectomy and isolated limb perfusion with urokinase in the treatment of phlegmasia cerulea dolens.

Phlegmasia cerulea dolens is a rare form of deep vein thrombosis. A patient with recurrent episodes of such thrombosis caused by protein C deficiency who developed phlegmasia cerulea dolens is reported. Limb perfusion with urokinase successfully restored venous outflow after unsuccessful attempts at thrombectomy.

Long-term follow-up comparing subclavian flap angioplasty to resection with modified oblique end-to-end anastomosis.

The definitive surgical procedure for correction of aortic coarctation remains controversial. Therefore, we retrospectively reviewed a total of 56 children under 4 years of age with coarctation repair between 1977 and 1986. Thirty-four had the subclavian flap angioplasty technique and 22 had resection with oblique end-to-end anastomosis. The group was further subdivided to include only the 23 infants less than 3 months of age--eight infants with resection with oblique end-to-end anastomosis (less than or equal to 3ETE) and 15 infants with subclavian flap angioplasty (greater than or equal to 3SFA). The remaining 33 patients older than 3 months of age were divided into 14 patients with resection and oblique end-to-end anastomosis (greater than 3ETE) and 19 patients with the subclavian flap angioplasty technique (greater than 3SFA). The overall mortality was not significantly different between techniques. Postoperative hypertension was significantly more prevalent with end-to-end anastomosis than with the subclavian flap angioplasty technique (p less than 0.01). Seven patients had recurrent coarctation. The 6-year actuarial freedom from recoarctation was 93% +/- 6% in the less than or equal to 3SFA group compared with 53% +/- 20% in the less than or equal to 3ETE group (p less than 0.02), but there was no significant difference in those children operated on at a later age regarding the type of coarctation repair. Therefore, we recommend subclavian flap angioplasty in patients less than 3 months of age. In those older than 3 months either procedure is safe and the risk of recoarctation is similar.