Results of combined valvular and myocardial revascularization operations.

A total of 105 patients underwent combined coronary artery and valvular operations. Sixty-six had combined coronary artery bypass grafting (CABG) and aortic valve replacement (AV), 28 had CABG and mitral valve operations (MV), and 11 patients had CABG and double or triple valve operations (DTV). An average of 3.0 bypasses was done, range one to seven. These patients were compared to a similar group of patients who underwent valve replacement(s) only, without CABG. Bypass time was increased for the combined groups, as was ischemic cross-clamp time. Early mortality was 3.0% AV, 3.5% MV, and 9.1% DTV in the combined groups and 1% in the valve only groups. The higher mortality for the combined groups was almost entirely due to the 23% mortality in women over 70 years of age. Perioperative myocardial infarction (MI) was higher in the combined groups (5% MI, 9% probable MI versus 2.9% MI, 4.1% probable MI). All survivors were in improved clinical condition and free of angina. Mortality and improvement were unrelated to perioperative infarction. The small increase in risk compared to the significant improvement from the combined approach has led to the following principles: coronary arteriography on all adult patients requiring valvular operations; bypass of all significant coronary lesions; restoration of valvular function and hemodynamics; and myocardial preservation with cold cardioplegia during a single period of cross clamping, topical cold, and systemic hypothermia.

Simplified method for reoperation on the mitral valve.

Reoperation on the mitral valve is becoming more common because of the degeneration of bioprosthetic valves, endocarditis, and malfunction or thrombosis of mechanical valves. We advocate a technique that transforms a technically difficult operation into one that is much less tedious, time-consuming, and dangerous than reopening a sternal-split operative site the second, third, or fourth time. Favorable experience in 11 patients using right anterolateral thoracotomy without aortic or right atrial cannulation and without aortic cross-clamping or cardioplegia is presented.

Use of the centrifugal flow pump for vena caval shunting.

We have used the Bio-Medicus centrifugal flow pump for vena cava shunting during surgical resection of renal cell carcinoma with extension of the tumor into the inferior vena cava. The active shunt can provide optimal blood return to the heart to promote hemodynamic stability, help provide an isolated field for resection of the involved kidney and its tumor extension into the vena cava, and avoid use of full-dose heparin to minimize blood loss in this extensive operation.

Prevention of ventricular fibrillation after aortic declamping during cardiac surgery.

Ventricular fibrillation is common after aortic declamping during cardiac surgery, and the metabolic demands of such fibrillation, or its treatment by means of countershock, may contribute to myocardial injury. To determine the effects of administering intravenous lidocaine just before aortic declamping, we randomly divided 194 cardiac surgery patients into 2 groups. One hundred patients (group A) received lidocaine, 200 mg intravenously, 3 minutes before aortic declamping; and 94 patients (group B) received no medication before declamping. Multiple baseline variables, including clamp times, medications, electrolyte values, ventricular function, and the extent and type of surgery, were similar for both groups. After aortic declamping, 31 of the 100 patients in group A had ventricular fibrillation, as did 57 of the 94 patients in group B (p < 0.001). Of those who fibrillated, the group-A patients required a mean of 1.76 countershocks, whereas the group-B patients required a mean of 2.68 countershocks (p < 0.05). Serum potassium level also affected the incidence of ventricular fibrillation, independently of lidocaine. Elevated serum potassium levels were associated with a lower incidence of ventricular fibrillation. Although lidocaine was independently protective at all potassium levels, the combination of lidocaine and a high serum potassium level had the greatest effect in preventing fibrillation. In patients who had potassium levels higher than 5.1 mEq/l and who were also given lidocaine, the incidence of ventricular fibrillation was lower than 15%.

Coronary revascularization in young patients.

From 1978 to 1982, 92 of our 1704 patients undergoing coronary bypass surgery were 40 years of age or younger. Eighty-six were male and six were female. The main indications for surgery were refractory angina and unstable angina. A family history of heart disease, smoking, and hypertension were major risk factors. The majority of patients had triple vessel disease, and six had left main lesions. Left ventricular function was moderately or severely impaired in 24. Coronary revascularization was performed with internal mammary and saphenous vein conduits, with a mean of 3.7 grafts per patient (range, 1 to 7). There was no operative mortality, but one patient required an intraaortic balloon pump. Perioperative infarction determined by Q waves occurred in one patient, while eight had enzymatic evidence of infarction. Late follow-up to 60 months showed three late deaths of cardiac origin. Eighty-three survivors were greatly improved, and 50 were asymptomatic. Sixty-five patients returned to work. Seventy percent of smokers stopped smoking; half the patients exercised regularly, and half maintained dietary modifications. Coronary bypass grafting is an effective rehabilitation procedure in the young. Long-term attention to risk factors and life style is required to maintain a beneficial outcome.

Delayed sternal closure as a safe adjunct to support biventricular failure after open heart surgery.

Over a four-year period, 22 patients of 2495 undergoing open heart surgery sustained severe biventricular failure (BVF) and would not tolerate primary sternal closure. Reasons for BVF included intraoperative injury, perioperative infarction, global dysfunction, cardiopulmonary edema, and intractable arrhythmia. Mechanical assist devices were required in nine patients. Average cardiac index fell to 1.1 L/min/m2 with attempts to close the chest, then stabilized at 1.9 with the sternum open and only soft tissue closed. After 3 to 11 days, cardiac index rose to 2.5 when assist devices were removed, inotropic agents decreased, and the sternum closed. Three early deaths (5-12 days) were caused by progressive biventricular failure. Five later deaths (19-64 days) were associated with renal and respiratory failure, superinfection, and sepsis. All of these required tracheostomy. Survival of 14 patients was not related to early low cardiac output, preoperative status, timing of sternal closure, or age, but was associated with early recovery of respiratory function without need for tracheostomy, avoidance of renal failure, and satisfactory alimentation. Sternal infection occurred in three patients, resulting in one death. The hospital stay ranged from 12 to 230 days. There was one death resulting from respiratory failure 14 months postoperatively. Our findings show that delayed sternal closure lessens early cardiac instability during BVF, helps allow recovery, and does not produce long-term disability.

En bloc caudate lobe and partial vena cava resection using a Gott shunt for retrohepatic caval bypass.

A technique of retrohepatic inferior vena cava bypass is described, useful for resection of the hepatic caudate lobe. A 77 year old female developed a solitary metastatic tumor mass in the caudate lobe compressing the Inferior Vena Cava (IVC), with cavography showing the IVC to be compressed, but patent. Without evidence of other metastatic disease radical resection of this tumor was performed. Successful resection was accomplished using a Gott shunt and porta hepatus compression for hepatic vascular isolation. No pump was used to avoid heparinization. Postoperative imaging confirmed IVC patency. The serum carcinoembryonic antigen (CEA) level fell to normal and remained so for 18 postoperative months. This introduces a new use of an atriocaval shunt for hepatic isolation during resection.

Hemodynamic comparison of albumin and hydroxyethyl starch in postoperative cardiac surgery patients.

The hemodynamic effects of 2 plasma volume expanders were compared in postoperative open heart surgery patients. Albumin 5% (A) or hydroxyethyl starch 6% (HES) solutions were infused according to indications based on cardiac index (CI) and pulmonary wedge pressure (WP), and their effects evaluated by physiologic profile measurements. Both groups demonstrated significant increases with volume infusion in CI (A from 2.37 to 2.84; HES from 1.97 to 2.49 L/min X m2) and WP (A from 9.4 to 13.7 mm Hg; HES from 11.9 to 13.2 mm Hg). Stroke index and stroke work increased similarly. Mean systemic arterial pressure (MAP) and mean pulmonary arterial pressure (MPAP) remained unchanged. No significant difference for any variable was demonstrated between the A and HES groups. In the volume used, from 250 to 750 ml, HES caused no bleeding abnormalities. HES is as effective as A as a plasma volume expander in postoperative cardiac surgery patients.