RESUMO
Intraaortic balloon pumping (IABP) is an established therapeutic adjunct in the treatment of postcardiotomy/infarction low cardiac output states. Although the common femoral or iliac arteries are the preferred sites for balloon insertion, severe arterial occlusive disease may preclude entry by these methods. To circumvent this problem, alternative methods of insertion utilizing transthoracic approaches have evolved. In our institution, direct (transaortic) IABP insertion, combined with delayed sternal closure to avoid cardiac compression and possible tamponade, was performed in 28 adult postcardiotomy patients (mean age 60.4 +/- 3 years). The severity of generalized atherosclerosis was reflected in an overall survival rate of 28.6%. Retrospective analyses of the clinical courses of these patients revealed that the transaortic approach allowed utilization of larger and more effective balloons. Successful insertion of 30 and 40 ml balloons was accomplished in 27 of 28 (96%) of these patients, and one patient with a hypoplastic aorta required a 20 ml balloon. There were no complications directly attributable to this alternative site of balloon insertion, and tamponade was avoided. Delayed sternal closure was accomplished within 48 to 96 hours. We concluded that when severe peripheral vascular occlusive disease prevents insertion of intraaortic balloons via the femoral or iliac arteries in patients with low cardiac output, the alternative transaortic approach is indicated. Combined with delayed sternal closure in patients with postcardiotomy dilatation, additional benefits accrue.
RESUMO
Two patients are presented in whom dissection of the ascending aorta resulted from cannulation for arterial return and from the infusion of cardioplegic solution. The dissections were recognized promptly. Following dissection in the first patient, the femoral artery was used to reestablish systemic perfusion. The aortic valve and dissected ascending aorta were replaced, and three vessels were grafted. In the second patient, the dissected anterior wall of the ascending aorta was excised and replaced with a low-porosity Dacron patch into which the proximal aortocoronary anastomoses were inserted. Predisposing factors are discussed, along with preventive measures and methods of repair.
RESUMO
A patient with a small aortic annulus had an apico-aortic conduit implanted for aortic stenosis approximately three years before being admitted to our institution. Four months after sustaining a steering wheel injury to the chest, he developed chest pain and palpitations. X-ray films and left ventriculograms revealed a large apical aneurysm of unknown duration. At surgery, it was noted that the proximal portion of the conduit had been sewn directly to the myocardium without the use of a rigid or soft apical outlet prosthesis incorporating a sewing ring. The aneurysm was resected along with a small proximal segment of the conduit graft. A polished Pyrolite(R) rigid inlet tube with a sewing ring and graft extension was inserted into the residual left ventricular apex, and continuity was reestablished with the abdominal segment of the conduit. It is postulated that the aneurysm was caused by either the direct anastomosis of the fabric graft to the apical myocardium at the original operation (with subsequent disruption and aneurysm formation prior to the steering wheel injury), or was the result of fixation of the heart at the diaphragm by the conduit, with increased vulnerability to deceleration injury at the direct left ventricular apex myocardium-fabric graft site.
