Routine use of unilateral and bilateral radial arteries for coronary artery bypass graft surgery.

OBJECTIVES: This study sought to evaluate the routine use of radial artery (RA) grafts in patients undergoing coronary artery revascularization. BACKGROUND: Previous long-term studies have documented poor patency of saphenous vein grafts compared with internal thoracic artery (ITA) grafts. METHODS: We performed a prospective review of 175 of 249 consecutive patients. RESULTS: Fifty-four patients had bilateral RAs harvested. Mean number (+/- SD) of grafts/patient was 3.27 +/- 0.93, with 2.76 +/- 0.97 arterial grafts; a mean of 1.53 +/- 0.68 grafts were performed with the RA. The operative mortality rate was 1.6%. No deaths were related to RA grafts, and there were no RA harvest site hematomas or infections. Transient dysesthesia 1 day to 4 weeks in duration occurred in the distribution of the lateral antebrachial cutaneous nerve in six extremities (2.6%). Elective cardiac catheterization in 60 patients at 12 weeks postoperatively demonstrated a 95.7% patency rate. CONCLUSIONS: Because of potential benefit of long-term patency associated with arterial grafts, minimal morbidity and mortality associated with use of the RA and excellent short-term patency rates, we cautiously recommend use of one or both RAs as additional conduits to be used concomitantly with the ITA for arterial revascularization of the coronary arteries.

Attempted nonsurgical electrical ablation of accessory pathways via the coronary sinus in the Wolff-Parkinson-White syndrome.

Previous canine experiments suggested that transvenous catheters placed in the coronary sinus could be used to deliver limited energy shocks, resulting in fibrosis in the atrial wall and coronary sulcus with sparing of the coronary artery. From the distribution of the fibrosis, it appeared that this approach could be used for attempted ablation of accessory pathways in patients with the Wolff-Parkinson-White syndrome. Eight patients with symptomatic Wolff-Parkinson-White syndrome underwent electrophysiologic testing with attempted ablation of 10 accessory pathways. Shocks were limited to 40 to 80 J, except in one patient who received shocks of 100 and 150 J. From 2 to 26 shocks were given to each accessory pathway. All the accessory pathways were blocked completely immediately after the shocks. Subsequently, evidence of accessory pathway conduction recurred in each patient. Three had early promise of long-term improvement after the procedure, with prolongation of the refractory periods of the accessory pathways during the remainder of the initial hospitalization. Several weeks later, however, there was evidence of return toward original values in two of these. Another patient who appeared not to benefit during her initial hospitalization returned 7 weeks later with very depressed accessory pathway conduction, possibly due to developing fibrosis. The only significant complication occurred in the patient receiving shocks of 100 and 150 J; he had apparent rupture of the coronary sinus requiring pericardial drainage. In two patients in whom nonsurgical ablation was not successful, intraoperative mapping showed that the accessory pathway was located in an area of fibrosis at the site of the attempted ablation. In summary, nonsurgical electrical ablation of accessory pathways via the coronary sinus may be successful using limited energy levels in a few patients. The procedure remains experimental, and widespread application must await more effective means of delivering the shocks.

Activation mapping in patients with coronary artery disease with multiple ventricular tachycardia configurations: occurrence and therapeutic implications of widely separate apparent sites of origin.

Catheter or intraoperative activation mapping studies, or both, were performed in 17 patients with coronary artery disease with two to four distinct configurations of ventricular tachycardia, resistant to a mean of 12.1 +/- 6.0 antiarrhythmic drug trials per patient. Mapping studies were performed to guide anticipated surgical ablation of arrhythmias. Activation map data were adequate to determine sites of origin of 30 (64%) of 47 observed tachycardia configurations. These 30 ventricular tachycardias (26 observed clinically) were mapped to 22 separate endocardial sites of origin. Sites of origin of distinct tachycardias were identical or closely adjacent (within 3 cm) in six patients and widely separate (greater than or equal to 4 cm) in eight patients (47% of the group). Activation maps were not adequate to determine sites of origin of 17 (36%) of the 47 tachycardias, including all configurations in three patients. Fifteen patients underwent surgery for control of ventricular tachycardia: aggressive, map-guided endocardial resection (mean 26.5 +/- 14.2 cm2) in 12 patients with identified sites of tachycardia origin and extensive resection of visible endocardial scar (2 patients) or encircling endocardial ventriculotomy (1 patient) in those in whom the sites of origin of all clinical tachycardias remained undetermined. Two inoperable patients were treated with amiodarone. During postoperative electrophysiologic tests (11 of 13 surgical survivors), ventricular tachyarrhythmias were initially uninducible in only 4 of 11 patients. However, in two patients only nonclinical arrhythmias (ventricular flutter) were induced. Six (21%) of 29 clinical tachycardias whose sites of origin were either not determined or not resected (right septum or papillary muscle) remained inducible in five patients. Using previously ineffective antiarrhythmic drugs, initially inducible arrhythmias became uninducible (two patients), or harder to induce than preoperatively (five patients). As a result of surgical resections alone or in combination with previously ineffective drugs (and amiodarone in two inoperable patients), there were no recurrences of ventricular tachycardia in 14 (93%) of 15 patients discharged during 19.0 +/- 14.3 months of follow-up study. Thus, activation mapping may commonly reveal separate apparent sites of origin for clinically observed, morphologically distinct, highly drug-refractory ventricular tachycardias in patients with coronary artery disease with multiple tachycardia configurations. Extensive surgical resection of identified sites of origin may be required to ablate arrhythmias in these patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Automatic implantable cardioverter-defibrillator: patient survival, battery longevity and shock delivery analysis.

The automatic implantable cardioverter-defibrillator (AICD) has been shown to reduce the mortality rate of patients with malignant ventricular tachyarrhythmias. This report describes experience with implantation of 36 automatic implantable cardioverter-defibrillators (AID-B and AID-BR models) in 22 persons over a 44 month patient follow-up period (mean 19.6 months). There were five deaths: two patients died suddenly 22 and 29 months, respectively, after their second implant, one died of congestive heart failure, one died of respiratory failure and one died of catheter sepsis. Although 11 (50%) of the 22 patients never received a countershock for a ventricular tachyarrhythmia and are still alive, the other 11 received one or more spontaneous countershocks. Nine patients (41%) experienced spurious shocks during the follow-up period. Assuming that the first shock for presumed ventricular tachyarrhythmia prevented death, the hypothetical cumulative survival of patients at 42 months would have been 34 +/- 14.1% in the absence of an automatic implantable cardioverter defibrillator rather than the actual survival rate of 59 +/- 16.8%. The cumulative device survival of the 36 AID-B units was 92 +/- 5.62% at 15 months but diminished to 37 +/- 14.4% by 20 months. No unit lasted longer than 22 months. There were 12 battery depletions. The number of shocks emitted did not influence unit longevity. The manufacturer's elective replacement indicator is of uncertain validity. Six units remained active 7 to 17 months after surpassing their replacement indicator. The automatic implantable cardioverter-defibrillator prolongs the life of many patients with otherwise intractable arrhythmias.(ABSTRACT TRUNCATED AT 250 WORDS)

Exacerbation of ventricular arrhythmias during the postoperative period after implantation of an automatic defibrillator.

The postoperative course of 68 consecutive patients treated with an implantable defibrillator during the period from 1982 through 1990 was studied. In 46 patients (group 1), no concomitant surgery was performed during the implantation. In 22 patients (group 2), concomitant surgery (coronary artery bypass [n = 12], valve replacement [n = 3] or arrhythmia surgery [n = 7]) was performed. All patients in group 1 were clinically stable before surgery, receiving an antiarrhythmic regimen chosen by serial drug testings. The same regimen was continued postoperatively. Eight of the 46 patients in group 1 whose condition had been stable in the hospital for 19 +/- 25 days preoperatively developed multiple episodes of sustained ventricular tachycardia 4 +/- 9 days after implantation while receiving the same antiarrhythmic regimen. Although the exacerbation was transient in some patients, six required different antiarrhythmic therapy and one eventually died. Two additional patients had frequent and prolonged episodes of nonsustained ventricular tachycardia that could trigger the defibrillator, requiring changes in the antiarrhythmic regimen. Another patient had progressive cardiac failure and died on day 5. A marked (sevenfold) increase in asymptomatic ventricular arrhythmias was noted in 42% of the remaining 35 patients. In group 2 (combined surgery), one patient developed refractory ventricular tachycardia 3 days postoperatively and died on that day. Three patients developed frequent nonsustained ventricular tachycardia postoperatively, requiring changes in the antiarrhythmic regimen. The overall surgical mortality rate was 4.4% (4.3% in group 1 and 4.5% in group 2) and was due to refractory ventricular tachycardia in two patients and cardiac failure in one.(ABSTRACT TRUNCATED AT 250 WORDS)

Benefits of implantable defibrillators are overestimated by sudden death rates and better represented by the total arrhythmic death rate.

Benefits of the implantable defibrillator on survival were studied in 56 consecutive patients (concomitant coronary bypass or arrythmia surgery in 15) during an 8 year period between 1982 and 1990. During a follow-up period of 29 +/- 25 months, six patients had a sudden death and eight patients had a nonsudden cardiac death. Nonsudden cardiac deaths included three surgical deaths (death within 30 days after the surgery; two in patients without and one in a patient with concomitant cardiac surgery), one arrhythmia-related nonsudden death (death within 24 h after an arrhythmic event despite initial termination of the arrhythmia by the implantable defibrillators) and four nonarrhythmic cardiac deaths. The actuarial survival rate free of events at 1, 2 and 3 years was 96%, 96% and 92%, respectively, for sudden death, 91%, 91% and 87% for sudden death and surgical mortality and 89%, 89% and 85% for total arrhythmic death (sudden death, surgical mortality and arrhythmia-related nonsudden death). Thus, in patients treated with an implantable defibrillator, 1) the rate of sudden death is low (8% at 3 years); 2) 50% of nonsudden cardiac deaths are causally related to arrhythmia (surgical mortality or arrhythmia-related nonsudden death); 3) the total arrhythmic death rate is substantially higher than the sudden death rate; and 4) benefits of an implantable defibrillator are overestimated by reported sudden death and nonsudden cardiac death rates. The benefits may be better represented by the total arrhythmic death and nonarrhythmic cardiac death rates.

Comparison of left ventricular cryolesions created by liquid nitrogen and nitrous oxide.

OBJECTIVES: This study was designed to compare the cryosurgical lesions produced by liquid nitrogen (-196 degrees C) and nitrous oxide (-76 degrees C). BACKGROUND: Cryosurgical ablation is a useful method of arrhythmia surgery, but information on the dimensions of cardiac lesions produced by modifying cryoprobe temperature is limited. METHODS: We compared the dimensions, volumes and electrophysiologic effects of cryolesions created by a liquid nitrogen cryoprobe (Group I) and a nitrous oxide cryoprobe (Group II) on the left ventricular myocardium in the beating canine heart. Exposure time was compared at 1, 2, 3 and 4 min. In each of 18 dogs, two to four lesions were created on the left ventricle and analyzed: 35 lesions created with use of the nitrous oxide cryoprobe and 30 lesions created with the liquid nitrogen cryoprobe. Lesions were measured at the time of induced death 6 weeks postoperatively and assessed by tissue staining with the Masson trichrome technique. RESULTS: The volumes (mm3) of the cryolesions created by the liquid nitrogen cryoprobe were significantly larger (p < 0.05) than those of lesions created by nitrous oxide: 826 +/- 163 versus 493 +/- 197 at 1 min; 1,101 +/- 327 versus 666 +/- 185 at 2 min; 1,356 +/- 318 versus 787 +/- 258 at 3 min and 1,735 +/- 534 versus 923 +/- 376 at 4 min. CONCLUSIONS: Decreasing the temperature of the cryoprobe by using liquid nitrogen increases the volume of the lesions. Programmed electrical stimulation before and 6 weeks after cryoablation indicated no arrhythmogenicity.

Comparison and frequency of ventricular arrhythmias after defibrillator implantation by thoracotomy versus nonthoracotomy approaches.

Postoperative exacerbation of ventricular arrhythmias has been reported in some patients treated with thoracotomy implantable cardioverter-defibrillators (ICDs). This phenomenon, which may be related to epicardial patch electrodes, may be less frequent after nonthoracotomy ICD implantation. In this nonrandomized study, postoperative arrhythmias in thoracotomy approaches (n = 52) were compared with those in nonthoracotomy approaches (n = 59). Preoperatively, all patients were clinically stable receiving an antiarrhythmic regimen chosen by serial drug testing. Nine of 52 patients in the thoracotomy group developed sustained ventricular tachycardia postoperatively while receiving the same antiarrhythmic regimen chosen preoperatively, and 1 patient eventually died. Two additional patients developed frequent and prolonged episodes of nonsustained ventricular tachycardia requiring changes in the antiarrhythmic regimen. In the nonthoracotomy group, only 3 of 59 patients developed sustained ventricular tachycardia and 1 developed frequent nonsustained ventricular tachycardia. Thus, only 4 of 59 patients in the nonthoracotomy group developed clinically significant ventricular arrhythmia during the postoperative period compared with 11 of 52 patients in the thoracotomy group (p < 0.05). Surgical mortality was 6% in the thoracotomy group, and 0% in the nonthoracotomy group. In the remaining clinically stable patients, a marked (sevenfold) increase in asymptomatic ventricular arrhythmias was noted in 15 of 39 patients in the thoracotomy group, and in 3 of 55 patients in the nonthoracotomy group (p < 0.05). Thus, postoperative exacerbation of ventricular arrhythmia, sometimes noted with thoracotomy approaches, is very rare with nonthoracotomy approaches.

Comparison of defibrillator therapy and other therapeutic modalities for sustained ventricular tachycardia or ventricular fibrillation associated with coronary artery disease.

Outcomes of 282 patients referred to the arrhythmia service at Montefiore Medical Center for sustained ventricular tachycardia (n = 214) or ventricular fibrillation (n = 68) associated with coronary artery disease were analyzed retrospectively. All patients underwent serial drug trials by electrophysiologic testing and Holter monitoring. Sixty-eight patients who did not respond to drug therapy were treated with implantable cardioverter-defibrillators (ICD group), and 214 patients were treated with other methods guided by electrophysiologic testing and Holter monitoring (non-ICD group). The non-ICD group included 49 patients who responded to drug therapy as judged by electrophysiologic testing, as well as patients who did not respond and were not treated with defibrillator therapy for various reasons. Ten patients died in the hospital (2 patients in the ICD group, 8 in the non-ICD group). Actuarial survival rates free of total cardiac death at 1, 2, and 3 years were, respectively, 94%, 87%, and 85% in the ICD group, and 82%, 78%, and 73% in the non-ICD group (p = NS). Survival rates free of total death at 1, 2, and 3 years were 90%, 82%, and 76% in the ICD group, and 82%, 76%, and 70% in the non-ICD group, respectively (p = NS). Survival rates free of total cardiac and total deaths of 49 patients treated with an effective regimen determined by electrophysiologic testing were not significantly different from those of the ICD group. This retrospective study suggests that outcomes of patients treated with ICDs may not be dramatically different from those of patients treated with other methods guided primarily by electrophysiologic testing.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of left ventricular function on survival and mode of death after implantable defibrillator therapy (Cleveland Clinic Foundation and Montefiore Medical Center experience).

To determine the influence of left ventricular (LV) function on survival and mode of death in patients with an implantable cardioverter-defibrillator (ICD), sudden death, surgical mortality, total arrhythmia-related death, total cardiac death and total death were retrospectively evaluated in 377 consecutive patients. The outcomes were also compared between patients with an LV ejection fraction > or = 30% (214 patients, group 1) and < 30% (148 patients, group 2). Surgical mortality was 3.9% (1.8% in group 1, 7% in group 2). During the follow-up of 25 +/- 20 months, actuarial survival rates of all patients at 3 years were 96% for sudden deaths, 81% for total cardiac deaths and 74% for total mortality. When the 2 groups were compared, survival rates of groups 1 and 2 at 3 years, respectively, were 99 and 90% for sudden death (p < 0.05), 97 and 84% for sudden death and surgical mortality (p < 0.01), 94 and 80% for the total arrhythmia-related death (p < 0.001), 88 and 68% for total cardiac death (p < 0.0001), and 81 and 62% for total mortality (p < 0.002). In group 2, 73% of total cardiac deaths within 1 year were causally related to the arrhythmia. Thus, in patients with an ICD, sudden death rates were very low. However, total cardiac death and total death rates were relatively higher. The outcomes of patients with an ICD were strongly influenced by the degree of LV dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of long-term outcomes of patients treated with nonthoracotomy and thoracotomy implantable defibrillators.

In 193 consecutive patients treated with implantable defibrillators at our institution, thoracotomy approaches were used in 87 patients and nonthoracotomy approaches in 106 patients. Long-term outcomes of the 2 groups were compared by the intention-to-treat analysis. Surgical mortality (30-day mortality) rates were 5.7% in the thoracotomy group and 0% in the nonthoracotomy group. Six of 106 patients who underwent nonthoracotomy implantation had a high defibrillation threshold and did not receive nonthoracotomy defibrillators. The duration of follow-up was 52 +/- 31 months in the thoracotomy group, and 23 +/- 15 months in nonthoracotomy group. Actuarial survival rates at 6 and 24 months were, respectively, 90% and 81% in nonthoracotomy patients and 89% and 80% in thoracotomy patients (p = NS). In patients with left ventricular ejection fraction <30%, surgical mortality was 0% by the nonthoracotomy and 10% by the thoracotomy approach. Despite the 10% difference in 30-day mortality, survival rates at 6 months were 85% in nonthoracotomy patients and 81% in thoracotomy patients. At 24 months they were 73% in nonthoracotomy patients and 74% in thoracotomy patients. Thus, this nonrandomized study suggests that while short-term survival is better in nonthoracotomy patients than thoracotomy patients, the difference in survival diminishes quickly during the first few months and disappears by 6 months. The results were similar in patients with severe ventricular dysfunction. Several important implantable-cardioverter defibrillator (ICD) trials initially utilized thoracotomy ICDs. Although questions may be raised with regard to applicability of such a trial in the era of nonthoracotomy ICDs, this study suggests that the results of such ICD trials will be largely applicable to patients treated with nonthoracotomy ICDs.

Removal of infected transvenous leads requiring cardiopulmonary bypass or inflow occlusion.

Infection, although uncommon, can be the most lethal of all potential complications after transvenous pacemaker implantation. The infection rate at our institution has been 0.56% (42 implants) during the preceding 17 years for 7435 transvenous pacemakers implanted in 4333 patients. Four of the 42 patients required use of cardiopulmonary bypass or inflow occlusion to remove the infected transvenous leads. Seven patients had their pacemakers implanted elsewhere and were transferred to our medical center for treatment. One patient died postoperatively because of persistent sepsis from a retained lead segment. All other patients survived, and none had recurrent infection. We recommend removal of all hardware if there is infection of the pacemaker system. If traction or other methods fail to remove the transvenous portion of the pacemaker system, open methods of removal, although rarely required, are safe and effective and should be used without delay.

Left ventricular outflow tract obstruction following repair of pneumococcal mitral annular abscess.

An unusual case of a mitral annular abscess caused by Streptococcus pneumoniae was diagnosed by transesophageal echocardiography. The patient underwent surgical resection of the abscess and developed outflow tract obstruction. This is an unusual complication of the surgical procedure. The outflow tract obstruction may have been due to anterior displacement of the mitral valve by the abscess.

Results of electrophysiologically guided operations for drug-resistant recurrent ventricular tachycardia and ventricular fibrillation due to coronary artery disease.

Over a 39 month period, 143 patients with coronary artery disease had programmed stimulation (PES) for recurrent ventricular tachycardia (VT) or ventricular fibrillation (VF). Twenty-two patients underwent operations. Ages ranged from 40 to 71 years; 20 of the 22 were men. All patients had coronary artery disease and 11 had left ventricular aneurysms. The mean ejection fraction was 31% (16% to 50%). Eighteen of the 22 patients underwent operations for drug-resistant ventricular arrhythmias (more than six different drugs plus drug combinations tested per patient). Nineteen patients had intraoperative mapping, endocardial resection, and/or an encircling endocardial ventriculotomy. Three patients with ischemia-related VT had coronary artery bypass (CABG) alone. The 30 day operative mortality was 14%. Thirteen of 19 (68%) operative survivors were effectively controlled with operation alone or a combination of operation and previously ineffective drug therapy. Of the six patients whose VT was inducible postoperatively, three have experienced episodes of sustained VT and one patient died suddenly. Three of these patients have the automatic implantable defibrillator. Operation guided by endocardial mapping is effective alone or in combination with drugs in this select group of patients. If the patients' VT was uninducible postoperatively with or without the addition of antiarrhythmic therapy, late deaths (3/19) were due to poor myocardial reserve and coronary artery disease, not the reemergence of sustained ventricular arrhythmias during a mean follow-up of 15 months.

Atrial natriuretic peptide replacement therapy in rats subjected to biatrial appendectomy.

The postoperative fluid retention found in some patients after the Cox maze procedure has been attributed to surgically induced loss of atrial natriuretic peptide. We postulated that exogenous atrial natriuretic peptide could reverse this antidiuresis. A rat model was used to investigate this hypothesis. In group I, the sham group, the atrial appendages were left intact and the animals were then subjected to a fluid challenge equivalent to 1% of the animal's body weight. In group II, after biatrial appendectomy, the animals were subjected to a fluid challenge similar to that in group I. Animals in group III underwent the same protocol as that for group II plus intravenous administration of atriopeptin III at varying concentrations. Urine output and plasma atrial natriuretic peptide levels were significantly decreased after biatrial appendectomies (p < or = 0.01). Urine output returned to control levels after biatrial appendectomies with low-dose atrial natriuretic peptide infusion (0.5 pmol/min = 25.5 pg/min), although circulating atrial natriuretic peptide levels were lower. Urine output and plasma atrial natriuretic peptide levels increased with atrial natriuretic peptide infusions between 0.5 and 50 pmol/min. Heart rate and mean blood pressure did not vary significantly with atrial natriuretic peptide infusions. Thus atrial natriuretic peptide can be used effectively in low doses to induce a diuresis after biatrial appendectomies. Atrial natriuretic peptide may have clinical application after the Cox maze procedure.

Single lung transplantation with cyclosporin immunosuppression. Evaluation of canine and human recipients.

Cyclosporin, a potent new immunosuppressive agent, was used (alone or in combination with other drugs) in 28 canine single lung allograft recipients. Mean recipient survival with good allograft function was 155 days with cyclosporin and far exceeded that obtained in previous single lung allograft recipients treated with standard immunosuppression (15 to 22 days). The results of these experiments were as follows: (1) 20% of the recipient animals exhibited no evidence of rejection whatsoever; (2) four of 28 animals survived more than 350 days with good allograft function; (3) 79% of the animals exhibited some evidence of rejection that was easily reversed in 74% of instances with corticosteroids; (4) 10 of 28 animals exhibited good lung allograft function 5 months or more after operation; (5) in cyclosporin-treated lung allograft recipients, rejection was diagnosed by the presence of infiltrate on chest roentgenogram, analysis of the cellular content of bronchoalveolar lavage samples, and decreased perfusion on 99mtechnetium lung scan; (6) complete healing without stenosis of the bronchial anastomosis occurred in 82% of the animals studied. One of two patients treated with cyclosporin after undergoing single lung allografting survived 7 weeks after transplantation and 4 weeks after contralateral pneumonectomy. Episodes of rejection were reversible, and the bronchial anastomosis healed normally. This overall experience indicates that cyclosporin, although not a perfect immunosuppressive agent, increases the likelihood of success with therapeutic single lung transplantation.

Early postoperative angiographic assessment of radial grafts used for coronary artery bypass grafting.

UNLABELLED: Despite a revival of interest in using the radial artery as an alternative conduit for myocardial revascularization, little angiographic documentation of early postoperative results has been presented, particularly in North America. Accordingly, 60 of 150 patients who underwent coronary artery bypass with radial arteries from November 1993 to July 1995 have had postoperative cardiac catheterization at our institution. The patency rate of the radial artery grafts was 95.7% (90 of 94 grafts patent) with an average internal diameter of 2.51 mm. Four radial artery grafts showed diffuse narrowing. The patency rate of the internal thoracic artery grafts was 100% with an average internal diameter of 2.25 mm. Three of 62 grafts demonstrated diffuse narrowing. Two of 24 (7.7%) saphenous vein grafts were occluded; the average internal diameter was 3.23 mm. The internal thoracic artery, the radial artery, and saphenous vein grafts were, respectively, 7.5%, 19.5%, and 53.3% larger than the anastomosed native coronary arteries. Graft-dependent flow was found in 81.1% of the radial artery grafts. CONCLUSION: The results of this study demonstrate that the short-term patency rate of radial artery grafts is excellent.

Staple suturing of the colon above the peritoneal reflection.

We review the few reports in the literature involving the results of stapled colonic anastomoses. Our personal experience with 88 consecutive stapled colonic anastomoses performed above the peritoneal reflection is analyzed. There were no mortalities and no evidence of anastomotic leaks in our series. With proper attention to the usual tenets of good colonic surgery and knowledge of the limitations of the stapling instruments, stapling colonic anastomoses is a safe technique.

Dextran 40-induced coagulopathy confused with von Willebrand disease.

In a patient who had undergone reconstructive surgery on the subclavian artery and was treated postoperatively with aspirin and dextran 40, a bleeding diathesis developed within 24 hours. This was at first thought to be von Willebrand disease, since the bleeding time was longer than ten minutes; the factor VIII level, 28%; and the activated partial thromboplastin time, 50 seconds (normal 30 to 38). The patient's defect responded to discontinuance of the low-molecular-weight, dextran and aspirin therapy and administration of a cryoprecipitate. Later studies of the coagulation mechanism up to two and one-half months were entirely normal. The postoperative defect therefore was assumed to have been the result of the administration of dextran and aspirin. It is possible that in a similar future case, discontinuance of dextran infusion and administration of a single bolus of 12 bags of cryoprecipitate may be adequate treatment.

Pacemaker implantation through the internal jugular vein.

During a twelve-year experience with 1,808 patients 90 underwent permanent transvenous implantation through the ligated internal jugular vein. Ninety-two implants were performed. In 2 of the patients both internal jugular veins were used without complication. Out of the ninety-two implants there were three complications; one permanent recurrent laryngeal nerve injury and two episodes of severe thrombophlebitis, which receded with nonoperative therapy. The internal jugular vein is a useful and safe route for permanent pacemaker implant.