The automatic implantable cardioverter-defibrillator. Clinical experience, complications, and follow-up in 25 patients.

Twenty-five patients with recurrent ventricular tachyarrhythmias underwent implantation of an automatic implantable cardioverter-defibrillator. The mean length of follow-up was 11.9 +/- 10.8 months. Before the implantation, the patients had survived one or more cardiac arrests (mean, 1.7; range, 1 to 4) and episodes of syncope (mean, 2.2; range, 2 to 3) and had received 6.0 +/- 1.0 antiarrhythmic drug trials. The in-hospital complications included death (two patients), reoperation (one patient), intraoperative myocardial infarction (one patient), sensing-failure (one patient), infection (five patients), and pocket seroma (two patients). The posthospital complications included device failure (four patients), device deactivation (one patient), and inappropriate discharge (two patients). The device discharged appropriately in seven patients due to sustained ventricular tachycardia. During electrophysiologic measurements, the energy requirement for successful cardioversion-defibrillation was related to the type of ventricular arrhythmia induced (monomorphic or pleomorphic ventricular tachycardia or fibrillation). Ventricular tachycardia acceleration occurred in ten patients (40%). No significant changes were found in the size of the electrograms or in the cardioversion threshold during early and late follow-up measurements. Life table analysis showed a 12-month survival rate of 86% and an arrhythmic death survival rate of 100%. We confirm the improved rate of survival in this high-risk group of patients, despite significant complications.

Diaphragmatic left ventricular aneurysm. Clinical features, surgical treatment, and long-term follow-up in 22 patients.

Although the formation of a left ventricular aneurysm (LVA) is a common and well-recognized complication of myocardial infarction (MI), diaphragmatic LVA is a rare clinical entity. Of 354 consecutive patients who underwent LVA resection, we describe the clinical features and surgical results of 22 patients (6%) with diaphragmatic LVA. All patients had a history of MI. The principal clinical indication for surgery was heart failure in nine patients, angina pectoris in ten patients, and recurrent ventricular tachycardia unresponsive to medical therapy in three patients. A ventricular septal defect was present in two patients, and moderate to severe mitral regurgitation was present in four patients. Three of the four surgical deaths (operative mortality, 18%) occurred in patients with mitral regurgitation or with ventricular septal defect. Eleven patients are alive at a mean follow-up of 40 months. Six of them are asymptomatic and two have angina at a higher level of physical activity than before surgery. Notable differences exist in the clinical presentation and surgical findings between patients with diaphragmatic and anterior LVA.

Occlusive disease confined to the right coronary artery: clinical features, surgical treatment and long-term follow-up in 124 patients.

The clinical presentation and surgical results in 124 consecutive patients who underwent aorta to right coronary arterial bypass surgery from January 1970 through June 1977 were reviewed. Preoperatively, 75 percent of the patients were in New York Heart Association functional class III or IV, 9 percent presented with unstable angina and 5 percent had life-threatening ventricular arrhythmias. All patients had high grade occlusive disease confined to the right coronary artery; 34 percent of the patients had associated nonsignificant disease (less than 50 percent intraluminal narrowing) of the left anterior descending or circumflex artery. Left ventricular function was normal in 63 percent and minimally impaired in 37 percent. The operative mortality rate was 1.6 percent. The course of the 122 survivors was followed up for 3.7 years. There were four late deaths, and the 5 year mortality rate was 4.0 percent. Eight patients were reoperated on because of recurrence of symptoms and occlusion of the graft or progression of occlusive disease of the other major coronary arteries, or both. Of the remaining 110 patients, 98 are either in functional class I or II, 60 are taking no cardiovascular medications, 52 are working full time without angina nad 73 are asymptomatic. In summary, bypass surgery for isolated right coronary artery disease has a low mortality rate and results in excellent long-term symptomatic improvement.

Leg wound complications associated with coronary revascularization.

One percent of 2,545 patients undergoing coronary revascularization with the saphenous vein over a 5 year period sustained leg wound complications which necessitated extra care. Fourteen complications were minor and required only drainage, a new antibiotic, and dressing changes. Thirteen major wound complications required wide debridement and, of these, five could be closed only with skin grafts. Eight wounds were infected, two with Staphylococcus aureus and six with mixed gram-negative flora. Ninety-three percent of these wounds were in the thigh. Average weight of patients with leg wound complications was 73.5 +/- 3.5 kg and not different from that of a randomly selected control group (73.8 +/-1.2 kg). However, 40% of the patients were women, a much higher incidence than control (p less than 0.005). Hospital stay increased significantly from 12.1 +/- 0.5 days for the control group to 24 +/- 2.6 days for the group with wound complications (p less than 0.005). Average hospital stay was 33.6 +/- 3.8 days (p less than 0.001) in those patients with major wound complications (estimated hospital cost $9,900). Leg wound complications of saphenous vein harvest are infrequent but serious. Efforts to prevent this complication should include minimal dissection, careful hemostasis, and closure in layers. Development of skin slough, infection, and necrosis necessitating débridement and drainage is a major and expensive complication. Wide excision and direct closure are necessary to minimize hospital stay and reduce the requirement for skin grafting.

Sternal wound complications. Management and results.

Of 4,124 patients undergoing median sternotomy for cardiac operations, 1.8% had sternal wound complications. These included wound drainage, skin separation, unstable sternum, and sternal dehiscence with or without infection. Septicemia and mediastinal abscess were found in all 19 patients who died. Incision and drainage of skin and subcutaneous tissue with frequent changes of dressing or irrigation (Method A) is recommended for those patients with (I) serosanguineous drainage only or (2) a stable sternum and superficial infection without systemic reaction. Surgical débridement of the sternum and mediastinum with reclosure followed by mediastinal irrigation via drainage tubes with 0.5% povidone-iodine solution (Method B) is recommended for patients with (1) a draining, unstable sternum, (2) infection involving the retrosternal space, or (3) infection causing a systemic reaction unresponsive to Method A. None of the eight patients in the latter group with more serious infections died when managed by Method B, and only one had recurrent infection. In contrast, of 28 patients of the latter group not treated with Method B, 11 died of infection-related causes and 13 returned with recurrent infection.

Abdominal aortic resection in thoracic dissection.

Dissection nearly always begins in the thorax, but it commonly extends into the abdominal aorta, which may become the focal point of the disease. We report five patients who illustrate the surgical management of this disease variant. Clinical manifestations included retroperitoneal rupture, expanding false aneurysm, and lower aortic occlusion. All patients had an aortic bifurcation graft, with reentry of the false lumen at the renal level. Two patients also had thoracic-aortic resection or plasty or both. Although one patient had thoracic aortic rupture at the five-year interval, these abdominal aortic resections provided effective palliation in all. This successful experience in managing complex dissections shows that when aortic dissection extends into the abdomen, resection of the distal aorta with a reentry procedure may be appropriate therapy.

Current surgical management of left ventricular aneurysm.

One hundred thirty-two patients with ventricular aneurysm had cardiac catheterization, coronary anglography, and ventriculography. More than 50 percent of the patients, in addition to aneurysmectomy, had other procedures consisting of revascularization, mitral valve replacement, and closure of ventricular septal performation. The overall mortality was 10 percent. Aneurysmectomy alone had a higher mortality (9 percent) when compared with combined resection of the aneurysm and coronary bypass (5.4 percent). During a six-month to 4-1/2-year follow-up (mean, 21 months), seven patients died, representing a late mortality of 6 percent. This study confirms the importance of complete cardiac evaluation in patients with ventricular aneurysm and shows that, in spite of extensive combined operative procedures required in more than 50 percent of the patients, the results are favorable.

Requirements for a method of transvenous inferior vena cava interruption.

Six requirements were defined that would characterize a safe and effective technique of transvenous inferior vena cava (IVC) interruption: (1) the instrument should be placed transjugularly under local anesthesia; (2) the instrument should have "built-in" capability for venography; (3) the technique should produce complete occlusion of the IVC; (4) the occluder must adapt to any variable in IVC diameter; (5) the intracaval device must have no sharp edges, pins, or points; and (6) the technique must permit simultaneous heparin therapy. These specifications were met by a catheter-delivered detachable balloon that could be inflated to any needed diameter. This technique was used in 96 patients, with a follow-up period to ten years. Time and experience confirm the validity of the six requirements for a safe and effective technique.

Aortic insufficiency secondary to aortic root aneurysm or dissection.

Twenty-four patients with aortic regurgitation secondary to aortic root aneurysm (13 patients) or dissection (11 patients) were operated on, utilizing a variety of surgical procedures to cope with the varied pathological findings. These ranged from primary repair of the ascending aorta without any prostheses in patients with acute aortic dissection to replacement of the valve and the entire ascending aorta for aortic root aneurysm. In four patients with Marfan syndrome the right coronary artery was transplanted to the ascending aortic graft, allowing an extension of the graft to the valve anulus and excision of the entire aneurysmal aorta. The immediate and late results have been most encouraging.

Simultaneous aortic and renal artery reconstruction.

From 1970 to 1978, 39 patients underwent simultaneous aortic and renal artery reconstruction. Of these, 37 had severe single or bilateral renal lesions in combination with an aortic aneurysm, or symptomatic or asymptomatic aortoiliac disease. Two patients had renal arteries that originated from an abdominal aortic aneurysm. Thirty-two patients were hypertensive, one had chronic renal failure, and three others had asymptomatic renal lesions that were bypassed prophylactically. Operations performed included aortic replacement plus: single renal graft; bilateral renal grafts; renal graft plus contralateral nephrectomy; and renal graft plus mesenteric revascularization. All early postoperative deaths (four) occurred in patients with aneurysmal disease. Twenty-nine patients were available for long-term evaluation. In patients who were hypertensive preoperatively, 64.0% experienced long-term cure or improvement. Cardiac and cerebral disease, lower extremity claudication, and the need for subsequent cardiovascular surgery occurred with substantial frequency during the follow-up period.

Late thrombosis affecting one limb of aortic bifurcation graft.

Late unilateral limb thrombosis was encountered in 45 of 601 patients discharged from the hospital with functioning aortic bifurcation grafts, an incidence of 7.5%. It was invariably associated with clinical manifestations of arterial insufficiency to the affected limb more serious than those of the extremity prior to the initial operation. Although the specific cause could not be determined, it was usually due to either progression of the disease distal to the reconstructed segment or to certain compromises at the time of the first operation or both. Among several procedures employed, unilateral reconstruction of the thrombosed limb is the procedure of choice. The reoperation was successful in 75% of the patients.

Acute renal failure complicating ruptured abdominal aortic aneurysm.

Ruptured abdominal aortic aneurysm complicated by renal failure is associated with a mortality greater than 90%. Aggressive management, which included the early use of hemodialysis, was employed. Between 1970 and 1973, a total of 43 patients had surgery for proved ruptured abdominal aortic aneurysm. Fourteen patients developed acute and fixed renal failure. Nine of these 14 patients had undergone hemodialysis with treatments beginning as early as the second postoperative day and lasting as long as ten weeks. There were six survivors, with a hospital mortality of 33%. This represents an improvement in survival compared with our earlier experience where the mortality in this type of patient was 93%. Early use of hemodialysis in the postoperative management of patients with acute renal failure complicating ruptured abdominal aortic aneurysm is recommended.

Carotid body tumor: resection or reflection.

We have studied a series of 24 cases of carotid body tumor, comprising our total experience during the past two decades. Twelve patients had symptoms related to compression or invasion of the surrounding structures. Two patients had malignant changes, while three individuals had bilateral lesions. Thirteen patients underwent neck exploration for diagnosis or attempt at surgical removal of the tumor prior to admission to our institution. Definitive procedures in 24 cases resulted in one postoperative death, a rate of 4%. Internal carotid flow was preserved in every case. Intraluminal shunting was employed during the last decade, and no instance of cerebral damage was encountered. It is our intention to emphasize the importance of an accurate diagnosis by carotid angiography prior to surgical management. We also wish to encourage routine excision of these tumors as they are diagnosed, before they reach an enormous size.

Mitral valve dysfunction following papillary muscle cryoablation.

Cryoablation is recognized as a useful modality for diagnostic mapping, as well as for permanent obliteration of arrhythmogenic foci. This technique has been used to eradicate irritable foci at the base of papillary muscles. We report a case of mitral valve dysfunction requiring valve replacement following cryoablation of the posterior papillary muscle. Based on this experience, we caution against extensive cryoablation of papillary muscle tissue because of the possibility of disrupting mitral valve function.

Surgical management of radiation-induced heart disease.

BACKGROUND: With the increasing population of patients with prior mediastinal irradiation, cardiac surgeons will encounter patients with radiation-induced damage to the heart and the great vessels. Awareness of the pathology and the surgical management is essential to provide optimal care for these patients. METHODS: Eight patients with radiation-induced heart disease were encountered in the last 10 years. After a brief clinical presentation, the surgical management of radiation-induced heart disease is reviewed. RESULTS: Radiation can affect all the structures in the heart, including the coronary arteries, the valves, and the conduction system. The pericardium is the most commonly involved, and the conduction system is the least involved. Pericardiectomy is quite effective in patients with symptomatic pericardial effusion or constriction. The coronary lesions are located predominantly in the ostial or proximal regions of the epicardial vessels. Percutaneous transluminal coronary angioplasty alone appears to have a high rate of restenosis. Surgical revascularization has good long-term results, and the internal mammary artery should be used if it is satisfactory. The aortic and mitral valves are more commonly involved than the tricuspid and pulmonary valves. Myocardial dysfunction predominantly affects the right ventricle and requires particular attention during cardiopulmonary bypass and in the postoperative period. Restoration of sinus rhythm is essential in view of stiffness of the ventricles. Flexibility in the surgical approach with selective use of thoracotomy will facilitate the surgical procedure in certain patients. CONCLUSIONS: Surgeons should be well versed in all the manifestations and the management of radiation-induced heart disease.

Transjugular forceps retrieval of catheter embolus.

Intracardiac migration of an intravenous cathether was treated transvenously in 5 patients successfully. Using local anesthesia and fluoroscopic guidance, a bronchoscopy forceps was passed through the right jugular vein to the right atrium and afforded efficient and safe retrieval of the embolus. The direct route to the right atrium provided by the right internal jugular vein and the precise control offerred by the rigid forceps make this the preferred method of retrieval of a transvenous catheter embolus.

Aortic valve replacement without left heart decompression.

Conventionally, during aortic valve replacement the left ventricle is vented to achieve a dry field, remove air, and prevent ventricular distention. This report demonstrates the feasibility of performing aortic valve replacement without cannulation of either the left ventricle or the left atrium. The technique has been utilized in 54 patients with 1 early death due to pulmonary embolism and 1 late death presumably secondary to ventricular arrhythmias.

Neurological complications of coronary revascularization.

In a series of 3,206 consecutive coronary artery bypass procedures performed between 1976 and 1981, 89 patients died (2.8% mortality) and 32 patients (1%) suffered major neurological syndromes. Among the latter patients, four distinct groups were identified. Group 1 consisted of 10 patients who remained unresponsive after operation. In Group 2 were 10 patients who awakened after operation but had clinical evidence of focal cerebral infarction. Group 3 included 6 patients who were initially intact neurologically but in whom neurological deficits later developed. In Group 4 were 6 patients who had severe mental aberration but no focal neurological deficits. The incidence of coma or focal deficit occurring without a lucid interval (Groups 1 and 2) was 0.62%, and these patients had a 30% mortality. Causative factors were suspected in 70% of the patients in Groups 1 and 2, and included atheromatous embolism, perioperative hypotension, carotid artery occlusive disease and air embolism. The outcome was poor for unresponsive patients, with 70% dying or remaining comatose, but nearly all of the patients with focal deficits or severe mental aberration demonstrated notable improvement.

Mitral insufficiency secondary to coronary heart disease.

Twenty-four patients were operated on for mitral regurgitation secondary to coronary heart disease. Their common features consisted of a history of myocardial infarction, congestive heart failure, coronary occlusive disease, left ventricular dysfunction, low cardiac output, pulmonary hypertension, and increased left ventricular end-diastolic pressure. Fourteen patients were in intractable congestive heart failure at the time of operation. The operative procedures employed consisted of aneurysmectomy in 4 patients; mitral valve replacement (MVR) in 7;MVR and revascularization in 4; MVR and aneurysmectomy in 5;MVR, revascularization, and partial ventricular resection in 3; and MVR with closure of ventricular septal perforation in 1 patient. Six patients died, a hospital mortality of 25%, and only 42% had good results. The degree of associated coronary artery disease and the status of the left ventricular myocardium were the most important prognostic factors.

Saccular outpouchings of an ascending aortic aneurysm: transesophageal echocardiographic appearance.

The differential diagnosis of cavities in the ascending aorta includes pseudoaneurysms, intimal flaps, and abscesses. We describe the transesophageal echocardiographic and pathologic appearance of a fusiform ascending aortic aneurysm that contained atypical outpouchings that were initially confused with an intimal flap. Awareness of this unreported abnormality and its echocardiographic features will avoid the misdiagnosis of more serious aortic pathology such as acute aortic dissection or infective endocarditis.