Ovarian function 6 years after cryopreservation and transplantation of whole sheep ovaries.

Whole ovary cryopreservation and transplantation has been proposed as a method for preserving long-term ovarian function. This work reports ovarian function 6years post transplantation of frozen-thawed whole sheep ovaries. Three 9-month-old Assaf sheep underwent unilateral oophorectomy to provide organs for the experiments. After perfusing with cold University of Wisconsin solution supplemented with 10% dimethyl sulphoxide, ovaries were cryopreserved using unidirectional solidification freezing technology. After thawing, ovaries were re-perfused and re-transplanted orthotopically by microvascular re-anastomosis, to the contralateral ovarian pedicle after removing the remaining ovary. Six years following transplantation and after inducing superovulation, the sheep were killed and the ovaries analysed. Two ovaries had normal size and shape showing some recent corpora lutea, while the third showed atrophic changes. A total of 36 antral follicles were counted by transillumination and four germinal vesicle oocytes were aspirated and matured in vitro to metaphase II. Serum progesterone concentrations were indicative of ovulatory activity in one of the three sheep. Histological evaluations revealed normal tissue architecture, intact blood vessels and follicles at various stages. Currently, this is the longest recorded ovarian function after cryopreservation and re-transplantation. Cryopreservation of whole ovaries, using directional freezing combined with microvascular anastomosis, is a promising method for preserving long-term reproductive capacity and endocrine function.

Acute hemodynamic effects of adjustable atrial septal defect closure in the lateral tunnel Fontan procedure.

OBJECTIVES: This study evaluated the acute hemodynamic changes with atrial septal defect closure in the postoperative period in patients undergoing the Fontan procedure. BACKGROUND: The adjustable atrial septal defect is a modification of the Fontan procedure designed to improve cardiac output and reduce systemic venous hypertension during the postoperative period. Limited information is available on the effects of inter-atrial shunting on the physiology of direct cavopulmonary connection. METHODS: In 11 patients (aged 9 months to 14.5 years), the atrial septal defect was closed 8 h to 4.6 days (mean 1.7 days) postoperatively. Indications for closure included mean right atrial pressure < 15 mm Hg or arterial oxygen saturation < 80%, or both. RESULTS: Data presented are mean values +/- 1 SD. Mean right atrial pressure was 13.4 +/- 3.0 mm Hg on admission to the intensive care unit, 10.0 +/- 2.0 mm Hg (p = 0.02) immediately before closure and 11.4 +/- 2.8 mm Hg (p = 0.02) after closure. There was a significant decrease in cardiac output, as calculated from arteriovenous oxygen saturation difference (26 +/- 9%, p = 0.003), Doppler aortic flow (19 +/- 9%, p = 0.0002) and ventricular volumes by two-dimensional echocardiography (20 +/- 8%, p = 0.0001). Arterial oxygen saturation increased from 82 +/- 5% to 94 +/- 4% (p = 0.0001), and arteriovenous oxygen saturation difference increased from 25 +/- 8% to 33 +/- 9% (p = 0.0001). Systemic oxygen delivery decreased from 727 +/- 354 to 655 +/- 325 ml/min per m2 (p = 0.02). One patient required reopening of the atrial septal defect. CONCLUSIONS: These data demonstrate that a controlled right to left atrial shunt improves cardiac output and systemic oxygen delivery and facilitates the postoperative management of patients after the Fontan procedure. Atrial septal defect closure increases systemic saturation to normal values and prevents potential systemic embolization but significantly decreases oxygen delivery and might limit exercise tolerance.

Frequency and significance of complete atrioventricular block after coronary artery bypass grafting.

Three hundred forty-eight consecutive patients were evaluated during 1985 and 1986 for the development of complete atrioventricular (AV) block after coronary artery bypass grafting. Cold (4 degrees) asanguineous potassium cardioplegia with temperature monitoring was used uniformly. AV block developed in 56 instances (16%). In 32 patients (group 1) the block was transient (less than 6 hours) and in 24 it was persistent (group 2). Left main coronary artery stenosis in conjunction with total obstruction of a dominant right coronary artery occurred more commonly in patients manifesting AV block (18 of 56, 32%) than in those without it (35 of 292, 12%) (p less than 0.05). Complete occlusion of a dominant right coronary artery was observed with equal frequency in patients with and without AV block. The presence of an ungraftable right coronary artery, however, was significantly more frequent in the AV block group: 16 of 37 (47%) vs 6 of 194 (3%) (p less than 0.01). Endarterectomy of the right coronary artery was performed in 8 of 24 patients (33%) with persistent AV block versus none in the patients with transient AV block (n = 32) or normal sinus rhythm postoperatively (n = 292) (p less than 0.0001). Persistent AV block (greater than 6 hours) was associated with myocardial infarction in 6 patients (25%) (p less than 0.05) and with low cardiac output in 18 patients (75%) (p less than 0.0001). In conclusion, AV block after myocardial revascularization was frequently associated with the presence of multivessel coronary disease and an ungraftable dominant right coronary artery. Persistent (greater than 6 hours) AV block was correlated with both perioperative myocardial infarction and low cardiac output.

Usefulness of late potentials on the immediate postoperative signal-averaged electrocardiogram in predicting ventricular tachyarrhythmias early after isolated coronary artery bypass grafting.

The present study was undertaken to determine the value of abnormal late ventricular potentials on signal-averaged electrocardiograms (ECG) in identifying patients at risk of developing ventricular tachycardia or ventricular fibrillation in the early postoperative period after coronary artery bypass grafting. Signal-averaged ECGs were recorded immediately after operation in 72 patients. Abnormal late potentials were defined as the presence of 2 or 3 of the following: (1) root-mean-square amplitude of the last 40 ms of the QRS < 20 microV; (2) duration of the terminal QRS potentials (after 40 microV) > or = 39 ms; and (3) high-frequency QRS duration > 120 ms (in patients with conduction defects, only the first 2 criteria were used). Abnormal late ventricular potentials were present on the immediate postoperative signal-averaged ECG in 26 of the 72 patients (36%). Life-threatening ventricular tachyarrhythmias occurred in 6 patients. Late potentials were present in all 6 patients, but only in 20 of 66 (30%) who did not develop ventricular tachyarrhythmias (p < 0.005) (sensitivity 100%, specificity 70%, predictive accuracy 72%). Of 12 pre- and perioperative variables examined by univariate and multivariate regression analysis, the presence of late potentials on the signal-averaged ECG and low cardiac output postoperatively were found to be independent predictors of life-threatening tachyarrhythmias.

Lung cancer resection or aortic graft replacement with simultaneous myocardial revascularization without cardiopulmonary bypass.

BACKGROUND: The concomitant occurrence of lung cancer or other thoracic problems requiring surgical treatment in patients with significant coronary artery disease is uncommon. METHODS: Three patients underwent revascularization of the anterior descending artery, without cardiopulmonary bypass, with simultaneous pulmonary lobectomy (two patients) or replacement of an obstructed descending aortic graft (one patient). RESULTS: Postoperative ventilation time was < 3 h, and no morbidity related to the combined procedure occurred during midterm follow-up. CONCLUSIONS: This one-stage approach allowed the immediate solution of two intrathoracic comorbidities, reducing expenses and suffering to the patients and minimizing the risk of bleeding or tumor dissemination secondary to extracorporeal circulation-induced coagulopathy and immunosuppression.

The inferior epigastric arteries as coronary bypass conduits. Size, preoperative duplex scan assessment of suitability, and early clinical experience.

We are currently evaluating the inferior epigastric artery as an alternative arterial conduit for coronary bypass grafting. Fifty-seven inferior epigastric arteries were harvested from 47 adults. There were no differences in size between the right and left inferior epigastric arteries. Diameter was 2.5 to 3.5 mm proximally and 2 to 3 mm distally. Usable length was 6 to 16 cm (mean 11.2 +/- 0.25 cm). Grade I/IV atherosclerosis was found in one patient (2.1%). Duplex scanning was used for preoperative evaluation of the inferior epigastric arteries in 51 patients. In 21 patients the arteries were not harvested, in part because of duplex scan findings of small caliber or early bifurcation. In 30 patients the duplex findings could be compared with the surgical findings. The average length at operation was twice the length detected on duplex scan (11.2 cm versus 5.8 cm, p less than 0.001). There was a good correlation between diameter on duplex scan and that measured at operation (2.56 +/- 0.05 versus 2.62 +/- 0.07, p = not significant). Between December 1989 and May 1991, 38 patients (29 to 74 years, mean 56 years) received 42 inferior epigastric artery grafts. Proximal anastomoses were to the aorta in 17, to the vein graft hood in 20, or onto an internal mammary artery graft in 5. Distal anastomoses were to the left anterior descending artery in 2, the diagonal branch in 27, the marginal branch in 9, or the right coronary artery in 4. There were no early deaths. Complications included perioperative myocardial infarction in 1, deep sternal wound infection in 2, superficial infection at the harvest site of the inferior epigastric artery in 5, and reexploration for bleeding in 2. Because of its size and the low incidence of atherosclerosis, the inferior epigastric artery may evolve as an alternative arterial conduit for coronary bypass. Duplex scanning is a valuable noninvasive tool for preoperative evaluation of the artery's suitability. Long-term studies of patency of the inferior epigastric artery as a coronary bypass conduit are needed.

Truncal valve repair: initial experience with infants and children.

The truncal valve regurgitation that frequently arises in patients with truncus arteriosus accounts for increased operative and late mortality. Five patients underwent truncal valve repair at UCLA Medical Center between August 1990 and September 1991. This group consisted of 2 infants who underwent complete repair and 3 who underwent valve repair together with right ventricle-pulmonary artery conduit replacement. The techniques used for repair were individualized according to the specific valve morphology, and consisted of the suturing of partially developed commissures, suspension of the cusps, resection of redundant portions of the cusps, annuloplasty at the commissures, and resection of excrescences on the surface of valve leaflets. In 1 infant who had a severely dysplastic truncal valve, stenosis and regurgitation recurred and progressed, and he died 4 months after truncal valve replacement. The remaining 4 patients, who were followed for from 8 to 21 months after repair, are in New York Heart Association class I, and have minimal or no aortic regurgitation. Except in patients with severely deformed and dysplastic valves, truncal valve repair can be an attractive and successful alternative to valve replacement.

Open heart operation after pneumonectomy.

A coronary artery bypass operation was performed successfully on a 70-year-old patient who had undergone left pneumonectomy 40 years earlier. This case, together with a search of the literature and a mail survey among 118 cardiothoracic surgeons worldwide, yielded data on 27 such patients for review. Two patients died perioperatively. Three patients had pneumothorax, and 1 patient had recurrent pleural effusion. Difficulty in exposing the circumflex marginal branches was reported in 2 patients after left pneumonectomy. We conclude that with attention to the specific features of the preoperative, intraoperative, and postoperative management, open heart procedures can be performed on patients after pneumonectomy with acceptable operative mortality and morbidity.

The danger in skin grafting the bare mediastinum after sternectomy for postcoronary bypass dehiscence.

We describe a patient who underwent coronary bypass grafting, after which severe mediastinitis and sternal osteomyelitis occurred. Repair after sternectomy was undertaken with a rectus-abdominis myocutaneous flap. The distal fifth of the flap underwent necrosis and was replaced by a meshed split-thickness skin graft. A year later, a clip marking one of the bypass grafts nearly eroded through the skin graft, endangering the bypass graft. The skin graft was removed by abrasion, and the bypass graft was covered with a pectoralis muscle flap. We recommend that skin grafting of a granulating wound over coronary artery bypass grafts be avoided if possible.

Damus-Stansel-Kaye procedure: technical modifications.

The Damus-Stansel-Kaye procedure has been applied for the relief of outflow tract obstruction caused by a restrictive bulboventricular foramen or subaortic stenosis in patients with complex univentricular heart disease. The procedure may also be part of a biventricular repair of a Taussig-Bing transposition of the great arteries. This report details technical modifications of the procedure to ensure unobstructed blood flow from the pulmonary artery to the aorta and to maintain the integrity of the pulmonary and aortic valves.

Autologous monocusp pulmonary valve: preliminary results.

BACKGROUND: There is growing recognition that postoperative pulmonary regurgitation may result in early or late progressive right heart failure. METHOD: A technique for fashioning an autologous monocusp pulmonary valve from the wall of the pulmonary artery was developed. The monocusp valve was fashioned from the anterior wall of the main pulmonary artery, and the remaining defect was filled with autologous pericardium. The procedure was performed in 8 dogs and 5 children. RESULTS: Early follow-up and serial echocardiographic assessment in both dogs and children proved the functionality of this monocusp pulmonary valve. All valves were pliable and demonstrated mild to moderate pulmonary stenosis and insufficiency. CONCLUSIONS: Construction of the autologous monocusp pulmonary valve is a feasible technique, and the valve performs efficiently. The acute performance in the canine model was excellent, and preliminary midterm results in the clinical study are reasonable. It is logical to assume that the monocusp, being an integral part of the arterial wall, will retain its viability and share in the subsequent growth of the pulmonary artery. Should follow-up studies demonstrate its long-term competence, this autologous valve may provide a good solution for various forms of pulmonary regurgitation and be useful in pulmonary autograft replacement of the aortic valve.

Preoperative duplex scan assessment of the inferior epigastric artery as a coronary bypass conduit.

The inferior epigastric arteries are currently being evaluated as alternative autologous arterial conduits for coronary artery bypass operations. The inferior epigastric arteries are variable in diameter and length and require harvesting through separate abdominal incisions. There is a need, therefore, for a method to preoperatively assess the diameter and length of the inferior epigastric arteries to determine their suitability as a coronary artery bypass graft. We have found that the duplex scan is a valuable noninvasive preoperative imaging modality to evaluate the inferior epigastric arteries.

Cardiac decompression after operation for congenital heart disease in infancy.

Between January 1987 and July 1992, 641 infants (less than 1 year of age) underwent cardiac surgical procedures through a median sternotomy incision at the UCLA Medical Center. In 36 (5.6%), to achieve cardiac decompression, the chest was left open after the operation, or was re-opened immediately postoperatively because of low cardiac output. The incidence of cardiac decompression was 31% (4/13) after the Norwood procedure and 24% (7/29) after truncus arteriosus repair. Opening of the chest reduced intrathoracic pressure and allowed complete expansion of the lungs. Delayed sternal closure was carried out in 27 patients at a mean of 5 days (range, 2 to 14 days) postoperatively. By the time of chest closure, left atrial pressure had decreased from a mean of 12 +/- 1.4 to 8.4 +/- 0.8 mm Hg (p < 0.004), and inotropic drug support with dopamine and dobutamine had also decreased significantly. Thirteen (36%) patients died of low cardiac output and multiorgan failure (4 of them after delayed chest closure) that was complicated by sepsis in 2. The incidence of sternal wound infection was relatively low at 5.6% (2/36); 1 patient died of generalized sepsis complicating multiorgan failure and the second case occurred in a patient who survived long term after sternectomy. With optimal ventilatory and inotropic drug support and meticulous wound care, delayed sternal closure may improve the survival of infants in low cardiac output after cardiac surgical procedures.

Damus-Stansel-Kaye procedure: current indications and results.

Between October 1983 and August 1991, 29 consecutive Damus-Stansel-Kaye procedures were performed. Indications for operation included restrictive bulboventricular foramen or subaortic stenosis associated with complex univentricular congenital heart disease (25) and Taussig-Bing heart, subaortic stenosis, or both associated with complex biventricular congenital heart disease (4). Twelve patients underwent concurrent Fontan procedures. Average age at operation was 39.8 months (range, 1 to 132 months). Average outflow tract gradient was 28 mm Hg (range, dynamic to 80 mm Hg). Of the 29 patients, 23 were male and 6 were female. There were three early deaths (10%), two in patients who had a concurrent Fontan procedure. Although there was a trend toward lower age and higher outflow tract gradients in nonsurvivors, these and other factors were not statistically significant predictors of death. Actuarial freedom from cardiac-related death was 88% at 5 years (n = 7). In a mean follow-up of 3.5 years (range, 0.1 to 7.7 years), 3 patients have required reoperation (10%), 2 for aortic valve insufficiency (5 days and 2.75 years) and 1 for a gradient across the anastomosis (5.75 years). Actuarial freedom from reoperation related to a failed Damus-Stansel-Kaye procedure was 90% at 4 years and 75% at 6 years (n = 7).

Tetralogy of Fallot, absent pulmonary valve, partial anomalous pulmonary venous return and coarctation of the aorta.

We describe a unique combination of tetralogy of Fallot, absent pulmonary valve, aortic coarctation with partial anomalous pulmonary venous connection and a retroaortic innominate vein. Surgical repair was successfully accomplished in two stages: coarctation repair preceded correction of the intracardiac anomalies.

Hemopericardium: a late complication after repair of pectus excavatum.

Hemopericardium and tamponade occurred in a 12 year old boy with Marfan's syndrome, two years after surgical repair of pectus excavatum. This life-threatening complication resulted from penetration of a fractured metal plate through the pericardium into the right atrium. The clinical details are reported and discussed.

Warm continuous antegrade blood cardioplegia: applications in congenital heart disease.

UNLABELLED: Continuous warm blood cardioplegia is utilized by many surgeons as their method of choice for myocardial protection during operations for acquired heart disease. OBJECTIVE: this study was performed to determine the feasibility and safety of this method for intracardiac procedures through the right atrium and in particular, total cavopulmonary connection. MATERIALS AND METHODS: procedures included closure of an atrial septal defect (23), atrial septectomy (2) and total cavopulmonary connection (4). Antegrade blood cardioplegia was delivered continuously for an average of 27 +/- 21 minutes at an average flow of 130 +/- 60 cc/min to maintain the aortic root pressure between 60 and 80 mmHg (mean 74 +/- 5 mmHg). Perfusion with regular blood commenced in the last 2 to 8 minutes and complete de-airing procedure was performed on the beating heart before removal of the aortic cross-clamp. RESULTS: all patients resumed sinus rhythm and all but one had normal cardiac output postoperatively. In one patient after cavopulmonary connection the inferior vena-cava to pulmonary-artery connection was taken down because of increased pulmonary vascular resistance resulting in low output state. All patients made an uneventful recovery without neurological complications. CONCLUSIONS: this initial experience suggests that normothermic aerobic arrest can be used safely in the repair of congenital defects and may provide superior myocardial protection for complex procedures such as the Fontan procedure.

Improved functional results following myocardial revascularization in patients with left ventricular dysfunction.

Between February 1978 and October 1982, 40 patients with preoperative ejection fraction (EF) of 0.35 or less underwent aortocoronary bypass. An average of 3.1 saphenous vein grafts per patient were inserted and revascularization was considered complete in 33 (82%) of the subjects in the group. Mean follow-up period was 29 months (range 12-65 months). Early mortality was 5% (2 patients) and there were seven late deaths (3 cardiac and 4 non-cardiac). The five-year cardiac actuarial survival rate was 74% +/- 13% (+/- SEM). Angina has improved in 29 (94%) of the 31 long-term survivors with 23 (74%) being totally asymptomatic. Twenty-two of the long-term survivors performed an exercise test at the end of their follow-up period. These tests revealed that bypass surgery in such patients results in significantly enhanced myocardial oxygen consumption with concomitant increase in effort level and duration. The exercise ability is probably directly related to the degree of revascularization.

Surgical treatment of post-infarction ventricular septal defect without concomitant myocardial revascularization.

Twenty one patients suffering from rupture of the ventricular septum (RVS) following acute myocardial infarction were operated upon between 1982-1985. Eighteen patients were operated upon urgently within 9.3 +/- 2.1 hours following diagnosis of RVS. In all, RVS occurred during the first infarction. None had concomitant myocardial revascularization. There were twelve operative survivors for an operative mortality of 42.5%. Two patients died 6 and 9 months postoperatively. All survivors are in functional class I, during a follow-up period of 14 to 56 months. The need for urgent repair of RVS is stressed and the value of concomitant coronary artery bypass is discussed.