Left atrial compression caused by hiatus hernia: a rare cause of syncope.

Symptomatic left atrial compression is a rare clinical condition presenting with heart failure, syncope or shock. A Med-line search with the term "left atrial compression" showed only 271 hits. Only 17 cases, of which 11 with hiatus hernia, of left atrial compression due to structures of the gastrointestinal tract were found. We describe a 86-year-old man suffering from repeating syncope due to left atrial compression by a hiatus hernia. This prompted us to review the few cases of atrial compression caused by gastro-intestinal structures.

Primary cardiac allograft failure after donor carbon monoxide poisoning treated with biventricular assist device.

Because of the current donor shortage, organ selection criteria are being progressively liberalized. We present a case of carbon monoxide poisoning in a multiorgan donor that led to primary cardiac allograft failure. A biventricular assist device was used as a bridge to recovery.

Should we use video-assisted endoscopic vein harvesting as a standard technique?

BACKGROUND: To investigate the feasability and results of endoscopic vein harvesting (EVH) using the Vasoview Uniport system (Guidant Corporation, Menlo Park,CA). Can this technique be used as a standard technique for vein harvesting in coronary artery bypass surgery (CABG) or is it too time consuming? Do smaller incisions result in less morbidity and discomfort? METHODS: From October 1998 to May 1999, 158 patients who underwent CABG with venous grafts, in addition to arterial grafts, formed the study population for EVH. In group A (n=131) the vein was harvested with the Vasoview Uniport System. In group B (n=27) the vein was harvested by a conventional open technique with interrupted incisions because of unavailability of the equipment. Recordings were made on vein length, harvest time, length of incision, and complications. RESULTS: In none of the patients in group A was a conversion to the open technique necessary. In 72/131, pure EVH was used. In 59/131 an additional incision below the knee was used for harvesting extra vein length. Mean harvested vein graft length (cm) was 35.9 (range 18-56) in group A and 30.6 (range 16-51) in group B, and mm of vein harvested/min was 77 and 71 in group A and B. Mean time for harvesting and closing (min) was 56.1 (range 14-120) SD 20.4 and 78.3 (range 37-129) SD 26 for a mean length of incision (cm) of six (range 2-19) and 27 (range 12-54). Wound complications at postoperative day three at discharge, and after six weeks were seen in 30 (23%), 27 (20%) and four (4%) patients of group A, and in five (18%), five (18%) and four (23%) of group B. CONCLUSIONS: Despite a learning curve in using endoscopic techniques, the total procedural time for EHV is acceptable and even shorter than open harvesting. Most of the time is gained in closure of the wound. Hematoma formation is the most common peroperative complication, but diminishes with experience. The absence of postoperative edema after EVH is striking. Despite the higher costs for disposable material, we have adopted EVH as a standard technique since patient and surgeon satisfaction have improved substantially.

Chronic osteomyelitis after sternotomy.

Two patients with chronic sternal osteomyelitis after an initially uncomplicated coronary artery bypass grafting (CABG) operation are described. Chronic osteomyelitis, caused in both cases by Pseudomonas aeruginosa, occurred six and four months after CABG respectively. Because chronic infection failed to respond to local wound care and medical therapy, more radical treatment was needed. Steel wires were removed and surgical debridement was performed. In one patient, an additional omental transposition was performed. In both cases radical debridement in combination with antibiotics successfully eradicated the infection.

Cardiac surgery in octogenarians.

OBJECTIVE: The elderly segment of the Western population is increasing rapidly, and cardiac surgeons are being asked to consider the very elderly for cardiac surgery. Our objective was to obtain data on the outcome of cardiac surgery in octogenarians in order to improve the indication for surgery and to give more accurate information to patients, family and general practitioners. METHODS AND RESULTS: From January 1990 through December 1998, 127 octo- and nonagenarians (age 80-94, mean 82.2 years) underwent cardiac surgery (coronary artery bypass grafting, valve surgery and aortic surgery) at the University Hospital of Antwerp. A retrospective review of the patients' medical records was performed. Follow-up information was obtained by mail or telephone from each patient's primary physician or cardiologist. Hospital mortality was 7.1% (9/127) and late mortality (mean follow-up 2 years) was 23% (30/127). Actuarial survival at 108 months was 70% (90/127). Eighty-three percent of the patients were having class III or IV anginal symptoms before operation. At follow-up 76% of the survivors were in NYHA class I or II. CONCLUSION: Cardiac surgery in the very old often permits survival with improved symptoms. Therefore surgery should not be refused solely because of old age.

Emergency ventricular assist device: better survival rates in non-post cardiotomy-related cardiogenic shock.

OBJECTIVE: The Abiomed BVS 5000 ventricular assist device (VAD) has been approved in Belgium for emergency cardiac support in patients with postcardiotomy failure with the aim of native heart function recovery. Other indications have emerged from world wide experience, but the indication and usefulness of emergency implantation of assist devices is often debated. METHODS: To decide which patients benefit most from emergency ventricular assist device implantation, we retrospectively reviewed our results of mechanical circulatory support with Abiomed in 20 patients over a 4-year period. Fifteen patients with mean age 58 +/- 6 years experienced postcardiotomy failure and underwent biventricular assist device (BVAD) implantation (group A), after elective (n = 9) or after emergency coronary artery bypass grafting (CABG) (n = 6). Five patients (group B), with mean age 35 +/- 19 years, had an implantation for other underlying conditions: hypertrophic cardiomyopathy (n = 3), myocarditis (n = 1) and primary cardiac allograft failure (n = 1). RESULTS: Of these two groups, eight and two patients respectively needed cardiopulmonary resuscitation before VAD implantation. The mean duration of support in both groups was 5.8 (range 12 h-13 days) and 4.4 days (range 2 h-9 days) respectively. Six and two patients could be weaned from the device and nine and one patients respectively, died on the device. Two patients in group B underwent successful heart transplantation and four patients in group A died after weaning. Two patients in the postcardiotomy group and four patients in group B survived (13% and 80%) with an overall survival and discharge rate of 30%. CONCLUSION: Although sample sizes are small, better survival rates with emergency Abiomed BVS 5000 implantation were obtained in the non postcardiotomy group (group B). For patients in the postcardiotomy group, outcome was negatively influenced by cardiac arrest and resuscitation before urgent CABG. Since death is the only alternative for these patients in cardiogenic shock and organ recovery cannot be predicted, we continue to consider emergency VAD implantation in this patient population.

Coronary artery bypass grafting on the beating heart using the Octopus method.

STUDY OBJECTIVE: To study the usefulness and effectiveness of off-pump coronary bypass grafting with the Octopus heart stabilizing device. METHOD: The files of thirty-one patients undergoing coronary artery bypass with the aid of the Octopus heart stabilizing device between April 1996 and October 1998 were studied retrospectively. Patients were divided into group A (n = 23), patients with single or double vessel disease and technically suitable coronary lesions for off-pump procedure and group B (n = 8), patients with multiple vessel disease considered to be with excessive risk for cardiopulmonary bypass due to poor general condition combined with renal failure and/or chronic obstructive pulmonary disease. Standard median sternotomy (n = 27), lateral thoracotomy (n = 1) or minithoracotomy (n = 3) were performed for access and for harvesting the left internal mammary artery (LIMA). MEASUREMENTS AND RESULTS: The mean number of bypasses was 1.2 and 1.1 in groups A and B, respectively. Thirty patients received a LIMA graft to the left anterior descending artery (LAD). Homologous blood transfusions were needed in five patients (21%) in group A and four (50%) in group B. There were no wound infections or neurologic complications. All patients in group A survived and are asymptomatic. One patient in group B died of septic shock, two have residual angina pectoris or dyspnea, and five are asymptomatic. CONCLUSION: Coronary artery bypass using the Octopus heart stabilizing device proved to be a safe and effective technique resulting in complete revascularization in group A patients with no mortality. Incomplete revascularization may offer a substantial benefit to patients who cannot tolerate cardiopulmonary bypass due to poor general condition. We prefer median sternotomy, allowing precise harvesting of the internal mammary artery and more precise anastomoses without increased morbidity.

Temporary mechanical support with the BVS 5000 assist device during treatment of acute myocarditis.

BACKGROUND: Ventricular support with the BVS 5000 (Abiomed) has been used as temporary circulatory assist for the failing heart. Our purpose is to summarize four cases illustrating the role of mechanical unloading in acute myocarditis. METHODS: Four patients aged 16- to 33-year old presented with congestive heart failure 4 to 20 days after a flu-like syndrome. All patients were in severe cardiogenic shock +/- renal and liver dysfunction. Ejection fraction ranged from 5% to 26%. Indications for ventricular assist were failure of maximal medical treatment with > or = two inotropes +/- intra-aortic balloon pump. Myocardial biopsy revealed acute myocarditis in three patients and severe edema in one despite a characteristic clinical course. Two patients received immunotherapy with OKT3. Biventricular assist was used in three patients and left ventricular assist only was used in one. Mean support time was 8.3 days (7 to 11). RESULTS: All patients had recovery of myocardial function and were discharged from the hospital in good condition. CONCLUSION: The BVS 5000 device provides a safe, simple, and effective method to support the circulation during acute myocarditis. We hypothesize that this may facilitate myocardial recovery by decompressing the distended ventricle. Ventricular assist devices should be used early in the presence of hemodynamic deterioration on maximal medical therapy.

Pressure recovery across the aortic valve.

The Bernoulli equation relates the pressure exerted on a fluid to its flow velocity and its density, in addition to its flow acceleration and its viscous friction loss. When flow velocity increases at a narrowing, the local pressure decreases proportionally. It has been wrongfully assumed that pressure lost distal to a stenosis can never recover. It is, however, the energy content of the fluid, equal to the kinetic plus the potential energy, which can not increase. When flow slows distal to a narrowing and little energy is lost to friction, pressure does actually increase. Pressure recovery has been well demonstrated to exist in a variety of pathophysiological states. Bicuspid aortic valve prostheses such as the St. Jude valves can produce quite remarkable pressure recovery. This causes a great discrepancy between pressure drop calculations based on continuous wave doppler on the one hand and true pressure drop across the prosthesis on the other. Reliance on doppler measurements only might wrongfully lead one to conclude that the prosthesis was malfunctioning. Less extreme pressure recovery is possible across a stenotic native aortic valve, but interpretation of the flow velocity across the valve might make the difference between recommendations to replace or to retain the valve. When interpreting doppler signals across narrowings the phenomenon of pressure recovery should be kept in mind.

N-acetylcysteine pretreatment of cardiac surgery patients influences plasma neutrophil elastase and neutrophil influx in bronchoalveolar lavage fluid.

OBJECTIVE: Study of leukocyte activation and release of toxic mediators during extracorporeal circulation (ECC). ECC can be used to study the potential protective effect of a pharmacon against neutrophil-mediated lung injury. Clinical studies have indicated that N-acetylcysteine (NAC) may improve systemic oxygenation and reduce the need for ventilatory support when given to patients with acute lung injury. DESIGN: Cardiac surgery patients were pretreated with high-dose NAC in order to assess the potential role of NAC to interfere with neutrophil-mediated inflammation and lung injury. PATIENTS: 18 patients who underwent ECC: group 1 (n = 8) no premedication (only placebo); group 2 (n = 10) NAC (72 mg/kg i.v. as a bolus, later 72 mg/kg over 12 h). MEASUREMENTS AND RESULTS: In group 2, the partial pressure of oxygen in arterial blood/fractional inspired oxygen 4 h after surgery was significantly higher than in group 1 (213 +/- 31 vs 123 +/- 22; p = 0.044). NAC pretreatment prevented an increase in plasma neutrophil elastase activity (18.9 +/- 6.9 vs 49.9 +/- 5.6 ng/ml in group 1 at the end of ECC; p = 0.027). Release of myeloperoxidase (MPO) was not affected (group 1:1105 +/- 225 ng/ml vs group 2:1127 +/- 81 at the end of ECC; p = 0.63). At the end of ECC, total antigenic human neutrophil elastase (group 1:671 +/- 72 ng/ml vs group 2:579 +/- 134; p = 0.37) and complex formation between elastase and alpha 1-proteinase inhibitor were no different in the two groups. There were no significant difference in cellular composition and mediators in the lavage fluid, although values for total number of neutrophils, elastase, MPO and interleukin-8 were lower in group 2. CONCLUSION: Pretreatment with NAC may prevent lung injury by diminishing elastase activity. Since the release of mediators, especially MPO, is not affected, this diminished activity of elastase may be achieved by enhanced inactivation by antiproteases after initial treatment.

Efficacy and safety of aprotinin in aortocoronary bypass and valve replacement operations: a placebo-controlled randomized double-blind study.

To assess the efficacy and safety of the use of a high-dose regimen of aprotinin in routine cardiac operations, a placebo-controlled randomized double-blind study was conducted in 93 adult patients undergoing cardiopulmonary bypass. Aprotinin-treated patients (group A, n = 46) received 2 x 10(5) Kallikrein Inactivating Units (KIU) of aprotinin before incision, 2 x 10(6) KIU in the priming solution and 5 x 10(5) KIU/h during CPB. Control patients (group B, n = 47) received the same volume of normal saline. Mean postoperative blood loss in ml after six hours and in total until removal of thoracic drains decreased significantly from 752 and 1933 in controls, to 358 and 1051 in treated patients (p < 0.001). Mean total transfusion needs were 2.6 (A) and 4.8 (B) units per patient. Adverse events were evenly distributed between both groups and could not be attributed to aprotinin use. We, therefore, recommend the use of a high-dose regimen of aprotinin for routine cardiac operations despite its cost.

Biventricular assist for severe acute rheumatic pancarditis.

Severe heart failure in acute rheumatic myocarditis is rare. It may be rapidly reversible with treatment, so maximal medical treatment and, if necessary, mechanical support should be given before heart transplantation is considered.

Nonfebrile mitral valve endocarditis due to Neisseria subflava.

Native valve endocarditis normally presents with fever and only later in its course demonstrates dysfunction of the affected valve. We describe a case of endocarditis due to Neisseria subflava, a Gram-negative diplococcal saprophyte of the oral cavity, which was unsuspected clinically and found unexpectedly during a mitral valve operation performed for symptomatic prolapse with regurgitation.

Right-to-left flow through a patent foramen ovale in acute right ventricular infarction. Two case reports and a proposal for management.

Right-to-left shunting through a foramen ovale complicating acute right ventricular infarction and resulting in severe arterial hypoxemia has been described eight times before. Treatment strategies have often aimed at reducing the shunt. Four patients died. Less attention has been paid to attempts at revascularization and, despite a high incidence of atrioventricular conduction disturbances, to temporary dual-chamber pacing. We describe herein two patients with postcardiac surgical right ventricular infarction complicated by severe right-to-left interatrial shunting. Treatment strategy was aimed at improving right ventricular function, and right-to-left shunting ceased. All efforts should be directed at treating right ventricular dysfunction, which is the cause of the clinical picture, and not at reducing the shunt, which is a secondary phenomenon.

Isolated coronary artery bypass grafting in patients 75 years of age and older: is age per se a contraindication?

137 patients with a mean age of 77.3 years (Group A) who underwent isolated coronary artery bypass grafting (CABG) were compared to 137 patients with a mean age of 55.6 years (Group B) who also underwent isolated CABG on the same or the adjacent day as the Group A patients. Group A patients were more commonly women, and had a significantly higher incidence of unstable angina, emergency operations, extensive coronary disease, peripheral vascular disease, and multiorgan debility. However, their left-ventricular function and the extent of revascularisation was similar to Group B patients. They also had significantly more operative mortality (7.2% vs 1.45%, p < 0.001). cardiac and non-cardiac complications, and longer hospital stay (14.2 vs 8.8 days, p < 0.001) than group B patients. At a mean follow-up of 29.8 months, no significant differences were noted in Group A versus Group B patients in terms of long-term survival (95% vs 94%), freedom from angina (82% vs 81%), cardiac readmission (10% vs 12%), or in the incidence of new myocardial infarction or new CABG. Actuarial survival at 4 years was 76.9% in Group A patients and 90.1% in Group B patients. Severe angina due to extensive coronary disease commonly makes urgent surgery unavoidable in this growing population of very old patients, but the operative mortality is modest and survivors do enjoy several years of life, remaining as free of angina, etc., as similar but younger patients.

Quality of life after heart valve replacement.

Over the last three decades, heart valve replacement has become a safe and routine surgical procedure, but replacement devices are still far from ideal. Despite improvements in materials and design, life-long anticoagulation remains mandatory for mechanical valves. The major shortcoming of the less thrombogenic bioprosthetic valves is early tissue failure. Parallel to the decrease in operative mortality after heart valve replacement, the potential quality of life for survivors has been becoming increasingly important in evaluating the late results and in selecting the appropriate device for the given patient. All factors that determine the quality of life are strongly affected by the operation due to the usually dramatic improvement both in subjective status and objective parameters postoperatively. The patient, thus, can return to normal activities, maintain self-esteem and keep normal relationships at work, in the community and at home. Psychoneurologic dysfunction was also found to decrease greatly within six months, although more than a quarter of patients were depressed preoperatively because of their disease. Overall, the experience was generally satisfying.