Purification of cardiac myocytes from human heart biopsies for gene expression analysis.

The collection of gene expression data from human heart biopsies is important for understanding the cellular mechanisms of arrhythmias and diseases such as cardiac hypertrophy and heart failure. Many clinical and basic research laboratories conduct gene expression analysis using RNA from whole cardiac biopsies. This allows for the analysis of global changes in gene expression in areas of the heart, while eliminating the need for more complex and technically difficult single-cell isolation procedures (such as flow cytometry, laser capture microdissection, etc.) that require expensive equipment and specialized training. The abundance of fibroblasts and other cell types in whole biopsies, however, can complicate gene expression analysis and the interpretation of results. Therefore, we have designed a technique to quickly and easily purify cardiac myocytes from whole cardiac biopsies for RNA extraction. Human heart tissue samples were collected, and our purification method was compared with the standard nonpurification method. Cell imaging using acridine orange staining of the purified sample demonstrated that >98% of total RNA was contained within identifiable cardiac myocytes. Real-time RT-PCR was performed comparing nonpurified and purified samples for the expression of troponin T (myocyte marker), vimentin (fibroblast marker), and alpha-smooth muscle actin (smooth muscle marker). Troponin T expression was significantly increased, and vimentin and alpha-smooth muscle actin were significantly decreased in the purified sample (n = 8; P < 0.05). Extracted RNA was analyzed during each step of the purification, and no significant degradation occurred. These results demonstrate that this isolation method yields a more purified cardiac myocyte RNA sample suitable for downstream applications, such as real-time RT-PCR, and allows for more accurate gene expression changes in cardiac myocytes from heart biopsies.

Intramyocardial injection of autologous platelet-rich plasma combined with transmyocardial revascularization.

Transmyocardial revascularization (TMR) can improve refractory angina but does not consistently demonstrate an effect on myocardial function. Recent studies suggest a synergistic effect between TMR and exogenously supplied growth factors. We evaluated the clinical role of intramyocardial injection of autologous platelet-rich plasma (PRP) in conjunction with TMR. Twenty-five nonrevascularizable patients with class III/IV angina underwent minimally invasive sole therapy TMR during a 5-year period at a single institution. Group 1 (14 patients) underwent TMR alone while group 2 (11 patients) underwent TMR plus injection of PRP (Magellan plasma separator) between TMR channels. Blinded angina assessment and ejection fraction (EF) were measured preoperatively and at 6 months postoperatively. Baseline EF (57 +/- 10% vs. 50 +/- 7%), angina class (3.7 +/- 0.5 vs. 3.7 +/- 0.5), and the number of channels (48 +/- 5 vs. 48 +/- 4) were statistically similar in both groups. At 6 months, two class angina relief was similar in both groups (92% vs. 100%, p = 0.4); however, the TMR + PRP group had a lower average angina score (1.3 vs. 0.4, p = 0.07) and more were angina free (23% vs. 78%, p = 0.04) than the TMR-alone group. EF improved in the TMR + PRP group (-2.0% vs. +9.0%, p = 0.07) compared to the TMR-alone group. Two 30-day morbidities occurred in the TMR-alone group (atrial fibrillation and left pleural effusion) and one mortality occurred in the TMR + PRP group. Intramyocardial injection of autologous PRP combined with TMR may be more efficacious at relieving angina and improving myocardial function than TMR alone.

Cardiac sympathetic denervation after transmyocardial laser revascularization.

BACKGROUND: Transmyocardial laser revascularization (TMR) has been shown to improve refractory angina not amenable to conventional coronary interventions. However, the mechanism of action remains controversial, because improved myocardial perfusion has not been consistently demonstrated. We hypothesized that TMR relieves angina by causing myocardial sympathetic denervation. METHODS AND RESULTS: PET imaging of resting and stress myocardial perfusion with [13N]ammonia (NH3) and of sympathetic innervation with [11C]hydroxyephedrine (HED) was performed before and after TMR in 8 patients with class IV angina ineligible for CABG or PTCA. A mean of 50+/-11 channels were created in the left ventricle (LV) with a holmium:YAG laser. A semiautomated program was used to determine NH3 uptake and HED retention in the LV. Perfusion and innervation defects were defined as the percentage of LV with tracer uptake or retention >2 SD below normal mean values. All patients experienced improvement in their angina by 2.4+/-0.5 angina classes after surgery, P=0.008. Sympathetic innervation defects exceeded resting perfusion defects in all patients before TMR (34.6+/-27.3% for HED versus 9.4+/-10.8% for NH3, P=0.008). TMR did not significantly affect resting or stress myocardial perfusion but increased the extent of sympathetic denervation in 6 of 8 patients by 27.5+/-15.9%, P=0.03. In the remaining 2 patients, both sympathetic denervation and stress perfusion defects decreased after surgery. CONCLUSIONS: TMR causes decreased myocardial HED uptake in most patients without significant change in resting or stress myocardial perfusion, suggesting that the improvement in angina may be at least in part due to sympathetic denervation.

Subxiphoid pericardial drainage for pericardial tamponade.

As a result of recent reports and enthusiasm for video-assisted thorascopic pericardiectomy, we reviewed our experience with subxiphoid pericardial drainage. From August 15, 1988, to June 7, 1993, 155 patients underwent subxiphoid pericardial drainage for pericardial effusion associated with pericardial tamponade. The group comprised 85 female (55%) and 70 male patients whose ages ranged from 5 weeks to 88 years. The procedure was carried out with general anesthesia in 113 patients (72%) and with local anesthesia and sedation in 42 patients. Underlying cancer was present in 82 patients; 73 patients had benign disease. Follow-up is complete in all patients. The overall 30-day mortality was 20%; in patients with cancer it was 32.9% (27/82) versus 5.4% (4/73) for patients with benign disease. No postoperative death was attributed to the surgical procedure. Recurrent pericardial tamponade necessitating further surgical intervention occurred in four patients (2.5%), two with cancer (2.4%) and two with benign disease (2.7%). Median survival after subxiphoid pericardial drainage in patients with benign disease was more than 800 days versus 83 days in patients with cancer (p < 0.01). Median survival after pericardial drainage in patients with cancer who had malignant pericardial effusion was 56 days compared with 105 days for patients with cancer who did not have tumor in the pericardium (p < 0.05). We believe that subxiphoid drainage is the procedure of choice for patients with pericardial tamponade. It is accomplished quickly, is associated with minimal morbidity, and prevents recurrent tamponade in 97.4% (151/155) of patients.

Transmyocardial laser revascularization combined with coronary artery bypass grafting: a multicenter, blinded, prospective, randomized, controlled trial.

OBJECTIVE: We sought to assess the safety and efficacy of transmyocardial revascularization combined with coronary artery bypass grafting in patients not amenable to complete revascularization by coronary bypass alone. METHODS: A total of 263 patients whose standard of care was coronary artery bypass grafting and who had one or more ischemic areas not amenable to bypass grafting were prospectively randomized to receive coronary bypass of suitable vessels plus transmyocardial revascularization to areas not graftable (n = 132) or coronary bypass alone with nongraftable areas left unrevascularized (n = 131). Group preoperative demographics and operative characteristics were similar. RESULTS: The operative mortality rate after coronary bypass/transmyocardial revascularization was 1.5% (2/132) versus 7.6% (10/131) after coronary bypass alone (P =.02). Patients undergoing both coronary bypass and transmyocardial revascularization required less postoperative inotropic support (30% vs 55%, P =.0001) and had a trend toward fewer insertions of intra-aortic balloon pumps (4% vs 8%, P =.13) than did patients having coronary bypass alone. Multivariable predictors of operative mortality were coronary artery bypass alone (odds ratio, 5.3; 95% confidence interval, 1.1-25.7; P =.04) and increased age (odds ratio, 1.1; 95% confidence interval, 1. 0-1.2; P =.03). One-year Kaplan-Meier survival (95% vs 89%, P =.05) and freedom from major adverse cardiac events defined as death or myocardial infarction (92% vs 86%, P =.09) favored the combination of coronary bypass and transmyocardial revascularization. Baseline to 12-month improvement in angina and exercise treadmill scores was similar between groups. CONCLUSIONS: In a prospective, randomized, multicenter trial, transmyocardial revascularization combined with coronary artery bypass grafting in patients not amenable to complete revascularization by coronary bypass alone was safe; however, angina relief and exercise treadmill improvement were indistinguishable between groups at 12 months of follow-up. Operative and 1-year survival benefits observed after adjunctive transmyocardial revascularization require confirmation by a larger validation study, which is ongoing.

Endoscopic saphenous vein harvesting.

Although the use of arterial conduit has decreased the amount of saphenous vein required for routine coronary artery bypass grafting, the saphenous vein as a bypass conduit remains an essential component of most practices. We describe the technique of endoscopic vein harvest that, in our initial experience with 30 patients, has improved patient satisfaction and decreased the complications associated with traditional harvest techniques.

Facile location of the saphenous vein during endoscopic vessel harvesting.

Endoscopic techniques are used more frequently to harvest the saphenous vein for cardiac and peripheral vascular procedures. To identify the saphenous vein through an initial small access incision can be difficult. We describe the use of a portable intraoperative ultrasound system to expeditiously identify the saphenous vein during endoscopic harvesting, particularly in obese patients.

Minimally invasive versus conventional reoperative coronary artery bypass.

BACKGROUND: Conventional reoperative (redo) coronary artery bypass grafting (CABG) is associated with significant morbidity. This retrospective study compared perioperative outcomes of conventional single-vessel redo CABG versus redo CABG done by a minimally invasive technique. METHODS: Group A consisted of 23 consecutive patients from September 1995 to July 1996 who underwent single vessel redo CABG of the left anterior descending artery with the left internal mammary artery using a limited anterior thoracotomy without cardiopulmonary bypass; group B consisted of 12 consecutive patients from November 1984 to July 1994 who underwent the same procedure using a median sternotomy with cardiopulmonary bypass. The two groups were similar with regard to age, sex, preoperative ejection fraction, and risk stratification. RESULTS: Mortality, cerebrovascular accidents, myocardial infarctions, and reoperations for bleeding were not significantly different between the groups. However, the patients in group A had significant reductions in atrial fibrillation, time to extubation, transfusions required, and length of cardiac recovery and hospital stay. With a mean of 12 +/- 6 months of follow-up, 87% of the patients in group A (20 of 23) are alive and asymptomatic. Actuarial survival rates for the patients in group B at 1, 2, and 10 years are 83%, 83%, and 72%, respectively. CONCLUSIONS: Minimally invasive single-vessel redo CABG can be performed safely and may reduce the morbidity associated with conventional single-vessel redo CABG.

Management of closed space infections associated with endoscopic vein harvest.

Wound complications are uncommon following endoscopic saphenous vein harvest. However, closed space infections within the endoscopic tunnel may occur and are difficult to manage. We describe the management of closed space infection in 3 patients and a method that allows drainage without unroofing the endoscopic tunnel.

Transhiatal stapled esophagojejunostomy without a pursestring suture in patients with previous gastric resection.

Previous gastric resection complicates alimentary tract reconstruction after esophagectomy. Colonic interposition is the standard conduit in this circumstance, but has substantial mortality and morbidity, especially important when treatment goals are to provide effective alimentation and minimize hospital stay. This report details the technique of a transabdominal, intrathoracic, stapled esophagojejunostomy created without a pursestring suture, which was used to reconstruct the esophagus in 3 patients who had previously undergone partial gastrectomy. This technique avoids both colon interposition and thoracotomy, thereby minimizing the associated complications.

Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage.

BACKGROUND: Optimal management of cardiac tamponade resulting from pericardial effusion remains controversial. METHODS: Cardiac tamponade in 117 patients was treated with either subxiphoid pericardiostomy (n = 94) or percutaneous catheter drainage (n = 23). Percutaneous catheter drainage was used for patients with hemodynamic instability that precluded subxiphoid pericardiostomy. Effusions were malignant in 75 (64%) of 117 patients and benign in 42 (36%) of 117. RESULTS: Subxiphoid pericardiostomy had no operative deaths and a complication rate of 1.1% (1 of 94). In contrast, percutaneous drainage had significantly (p < 0.05) higher mortality and complication rates of 4% (1 of 23) and 17% (4 of 23), respectively. Patients with an underlying malignancy had a median survival of 2.2 months, with a 1-year actuarial survival rate of 13.8%. In comparison, patients with benign disease had a median survival of 42.8 months and a 1-, 2-, and 4-year actuarial survival rate of 79%, 73%, and 49%, respectively (p < 0.05). Effusions recurred in 1 (1.1%) of 94 patients after subxiphoid pericardiostomy compared with 7 (30.4%) of 23 patients with percutaneous drainage (p < 0.0001). CONCLUSIONS: Benign and malignant pericardial tamponade can be safely and effectively managed with subxiphoid pericardiostomy. Percutaneous catheter drainage should be reserved for patients with hemodynamic instability.

Endoscopic versus traditional saphenous vein harvesting: a prospective, randomized trial.

BACKGROUND: Saphenous vein harvested with a traditional longitudinal technique often results in leg wound complications. An alternative endoscopic harvest technique may decrease these complications. METHODS: One hundred twelve patients scheduled for elective coronary artery bypass grafting were prospectively randomized to have vein harvested using either an endoscopic (group A, n = 54) or traditional technique (group B, n = 58). Groups A and B, respectively, were similar with regard to length of vein harvested (41 +/- 8 cm versus 40 +/- 14 cm), bypasses done (4.1 +/- 1.1 versus 4.2 +/- 1.4), age, preoperative risk stratification, and risks for wound complication (diabetes, sex, obesity, preoperative anemia, hypoalbuminemia, and peripheral vascular disease). RESULTS: Leg wound complications were significantly (p < or = 0.02) reduced in group A (4% [2 of 51] versus 19% [11 of 58]). Univariate analysis identified traditional incision (p < or = 0.02) and diabetes (p < or = 0.05) as wound complication risk factors. Multiple logistic regression analysis identified only the traditional harvest technique as a risk factor for leg wound complications with no significant interaction between harvest technique and any preoperative risk factor (p < or = 0.03). Harvest rate (0.9 +/- 0.4 cm/min versus 1.2 +/- 0.5 cm/min) was slower for group A (p < or = 0.02) and conversion from endoscopic to a traditional harvest occurred in 5.6% (3 of 54) of patients. CONCLUSIONS: In a prospective, randomized trial, saphenous vein harvested endoscopically was associated with fewer wound complications than the traditional longitudinal method.

Endoscopic and traditional saphenous vein harvest: a histologic comparison.

BACKGROUND: Vein trauma after saphenectomy by endoscopic or longitudinal techniques may influence the progression of medial and intimal hyperplasia and ultimately affect graft patency. This study compared the histologic characteristics of saphenous veins after endoscopic and longitudinal harvest. METHODS: One hundred seventy patients who underwent elective coronary artery bypass grafting had saphenectomy performed endoscopically (n = 88) or by a longitudinal incision (n = 82). Cross-sectional specimens from endoscopically (n = 151) and longitudinally (n = 158) harvested veins were submitted for hematoxylin-eosin, trichrome, and elastin staining. Blinded histologic evaluation involved graded analysis of endothelial, smooth muscle, and elastic lamina continuity in addition to medial and adventitial connective tissue uniformity. RESULTS: Regardless of harvest technique, endothelial, elastic lamina, and smooth muscle continuity as well as medial and adventitial connective tissue uniformity were not significantly different. CONCLUSIONS: Minor histologic alterations occur during saphenectomy, however, endoscopically and longitudinally harvested saphenous veins are histologically similar.

Transmyocardial revascularization utilizing a holmium:YAG laser.

OBJECTIVE: To evaluate the efficacy of transmyocardial revascularization performed on patients with refractory class IV or unstable angina with a holmium:yttrium-aluminum-garnet laser. METHODS: Transmyocardial revascularization with a holmium:yttrium-aluminum-garnet laser was performed in 42 patients with refractory angina who were not candidates for percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. Patients had either Canadian Heart Association class IV angina (n = 23) or unstable angina (n = 19) and were unable to be weaned from intravenous nitroglycerin. Preoperative thallium studies identified the extent and location of reversible ischemia. Operative exposure was via a limited left anterior thoracotomy. An average of 45+/-11 laser channels were created with a mean operative time of 106+/-38 min. RESULTS: Perioperative mortality was 12% (5/42) with no late deaths. Complications included ventricular 7.1% (3/42) and atrial 4.7% (2/42) arrhythmias, reoperation for chest-wall hemorrhage 2% (1/42), and respiratory failure requiring reintubation 2% (1/42). Intra-aortic balloon pump placement was required in 12% (5/42). The mean postoperative length of stay was 5.5+/-4.9 (1-25) days. Mean follow-up on 100% of patients is 5.4+/-3.0 (1-12) months. At 3 (n = 33) and 6 (n = 21) months follow-up the mean angina class was 1.5+/-0.1 (P < 0.002) and 1.1+/-0.1 (P < 0.001), respectively. CONCLUSIONS: Transmyocardial revascularization utilizing a holmium:yttrium-aluminum-garnet laser resulted in a significant reduction in angina class and was beneficial in patients with refractory angina untreatable by conventional methods.

Spontaneous pneumoperitoneum. A surgical dilemma.

Pneumoperitoneum is usually the result of hollow viscus perforation with associated peritonitis. Nonsurgical spontaneous pneumoperitoneum incidental to intrathoracic, intra-abdominal, gynecologic, iatrogenic, and other miscellaneous causes not associated with perforated viscus have been documented in the literature. Seven cases of spontaneous pneumoperitoneum admitted over 3-year period to Grady Memorial Hospital, Atlanta, Georgia are reported. Six patients with pneumoperitoneum underwent exploratory laparotomy when clinical examination suggested an acute abdomen; no intra-abdominal pathology was documented in any of these patients. A seventh patient, on ventilatory support, was managed conservatively after performing a diagnostic peritoneal lavage that was negative. There were no cases of radiographically misdiagnosed pneumoperitoneum. Pneumoperitoneum, preceded by a reasonable incidental cause in a patient with a adequate abdominal examination, may warrant continued observation thus avoiding an unnecessary laparotomy.

Malignant fibrous histiocytoma of the pancreas.

Malignant fibrous histiocytoma (MFH) is a well-recognized soft-tissue sarcoma; however, its presentation as a primary neoplasm of the pancreas is unusual. We report a rare case of primary MFH of the pancreas treated with wide local excision and postoperative chemotherapy. Three cases of MFH of the pancreas have previously been reported in the world literature. The natural history of MFH of the pancreas cannot be summarized due to the rarity of the tumor. It appears, however, that the behavior of this tumor parallels the behavior of retroperitoneal MFH in terms of aggressiveness and poor prognosis.

Surgery for achalasia of the cardia in children: the Dor-Gavriliu procedure.

The Dor-Gavriliu procedure was utilized in six children with achalasia of the cardia from 1983 to 1991. Four boys and two girls (mean age, 10.1 years; range, 3 months to 16 years) presented with symptoms of weight loss (83%), emesis (83%), dysphagia (67%), recurrent respiratory infections (67%), and nocturnal regurgitation (33%). The diagnosis of achalasia was established by barium swallow in all patients; esophageal manometry was used in four patients to confirm the diagnosis. Follow-up ranged from 10 months to 8 years (mean, 3.5 years). Four neurologically normal patients had excellent results with complete resolution of their preoperative symptoms. Two neurologically impaired children, both afflicted with Down's syndrome, had less than excellent results. One moderately impaired child had a good result (required three postoperative bougie dilations over 8 years without demonstration of gastroesophageal reflux); the second, more severely impaired child, had only a fair result (persistent failure to thrive with the development of grade II gastroesophageal reflux). The Dor-Gavriliu procedure uses a transabdominal, anterior esophageal myotomy with incorporation of an effective, nonobstructing, antireflux mechanism that should prevent myotomy reapposition.

Pediatric wandering spleen--the case for splenopexy: review of 35 reported cases in the literature.

Wandering spleen is an uncommon diagnosis and has been rarely described in children. A review of the English literature yielded 35 reported cases in children less than 10 years of age. Eighteen (51%) presented as acute surgical emergencies, only eight of which had the correct diagnosis of pedicle torsion with splenic infarction established preoperatively. Thirteen patients underwent an elective laparotomy, either for chronic symptoms related to their wandering spleen or for an abdominal mass. Of the 13 patients electively managed, nine underwent a splenectomy while five were treated successfully with splenopexy. The remaining four patients were managed conservatively without surgical intervention. In only one third of the patients presenting as acute surgical emergencies was there any history of intermittent abdominal pain or of a previous abdominal mass. No deaths were reported. Males represented 63% of the patients. The occurrence was most common in patients less than 1 year of age, with a 6:1 male predominance in this age category. All acute cases of wandering spleen in which splenic infarction has occurred require splenectomy. However, in patients with chronic symptoms or in whom the diagnosis is made prior to splenic infarction, splenopexy should be the treatment of choice. Past recommendations of splenectomy or conservative nonsurgical management are not indicated. Literature on pediatric wandering spleen is reviewed herein, and a technique for splenopexy using Dexon mesh is described.