A possible role for antiphospholipid antibodies in acquired cardiac valve deformity

We studied the frequency of antiphospholipid antibodies (aPL) in patients undergoing cardiac valve replacement, and present the results in the context of the pathology of the valve lesions. Forty-eight consecutive patients undergoing valve replacement were studied. Of the whole group, 15 (31%) had antibody levels greater than 2 SD above the mean for a control group of healthy persons and 11 (23%) had a level of greater than 3 SD. There was an increased frequency of elevated antibody levels in patients with valves showing fibrocalcific change and a significant association between aPL and valve thrombus. The possible role of these antibodies in the pathogenesis of the valve lesions is discussed.

Repair of isolated, symptomatic, sinus of Valsalva aneurysm in a patient with Marfan's syndrome

A 29-year-old man with Marfan's syndrome presented with sudden onset of central chest pain radiating to the back. Aortography revealed a massively dilated right sinus of Valsalva aneurysm, with moderate aortic regurgitation. Urgent surgery in the form of a Bentall procedure was successfully carried out. There was no evidence of either aortic rupture or dissection. Acute expansion of the aneurysm must have precipitated the symptoms. The patient was alive and well three months later.

Gastroepiploic-coronary anastomosis. A viable alternative bypass graft

Although increasing use is being made of arterial grafts (the internal mammary arteries) for direct myocardial revascularization, it is frequently not possible to reach the posterior surface of the heart with the internal mammary as either a pedicle or a free graft. Since June 1984 we have used the right gastroepiploic artery in nine patients as a pedicle graft to the distal right coronary artery (four patients), the posterior descending artery (three patients), and the distal circumflex branches (two patients). Eight patients survived the operation. Celiac axis opacification confirmed patency in six and coronary angiography strongly suggested patency in the remaining two. All survivors are functionally in New York Heart Association Class I or II. The early angiographic and clinical results demonstrate the feasibility of using the right gastroepiploic artery as a bypass graft to coronary vessels on the posterior surface of the heart when traditional conduits are unsuitable. If its long-term patency as a living arterial graft is similar to that of the internal mammary arteries, the gastroepiploic artery may become the coronary bypass graft of choice for the distal right coronary and circumflex systems.

A new surgical technique to correct double chambered right ventricle associated with anomalous left anterior descending coronary artery

A 42 year old woman with symptomatic double chambered right ventricle had the additional features of an anomalous left anterior descending coronary artery and attachment of the tricuspid valve to the area of subinfundibular stenosis which precluded conventional repair. A non-valved Dacron conduit was used to bypass the obstruction. The patient is asymptomatic two years later.

Massive endobronchial hemorrhage during cardiopulmonary bypass: treatable complication of balloon-tipped catheter damage to the pulmonary artery

Massive endobronchial hemorrhage due to balloon-tipped catheter rupture of a branch of the pulmonary artery in a fully heparinized patient undergoing cardiopulmonary bypass is potentially lethal. Death occurs due to asphyxiation. Endobronchial intubation (double-lumen endotracheal tube) appears to be a simple and effective method for control of the airway and tamponade of the bleeding site, which allows for completion of the surgical procedure until protamine sulphate reversal can be achieved.

Acute respiratory insufficiency from an aneurysm of the descending thoracic aorta

A 70-year-old woman presented with life-threatening acute respiratory insufficiency resulting from tracheobronchial compression by a large calcified expanding aneurysm confined to the descending thoracic aorta. This combination has not previously been reported. Successful surgical correction was carried out. This report describes in detail the presentation, diagnosis, and steps involved in the management of this entity.

Malfunction in a St. Jude medical mitral valve prosthesis: a clinical diagnostic dilemma

Thrombosis of one leaflet of a St. Jude medical prosthetic mitral valve in a 49-year-old man resulted in prosthetic malfunction causing cardiac failure. Clinical and echocardiographic assessment did not adequately distinguish between abnormal valve function and left ventricular dysfunction as the responsible lesion. Hemodynamic study revealed a gradient across the mitral valve and poor left ventricular function. At operation it was found that thrombus had caused one of the leaflets to stick in an almost open position. This malfunction was attributed to lack of adequate anticoagulation and to the impingement of a piece of papillary muscle on the prosthesis. A definite echocardiographic pattern for malfunction of the St. Jude valve has not been established. However, it is clear that loudness of prosthetic valve sounds cannot be used as a guide to normal function in a bileaflet valve.

Fate of omental graft after revascularization of the heart

Three patients who had had epicardiectomy, and internal mammary artery and omental grafts implanted as part of myocardial revascularization, recently underwent a second operation for coronary artery bypass grafting. All internal mammary artery implants were patent and appeared to revascularize the myocardium distal to the occluded segment of the coronary artery, as determined by angiography. Although adhesions were present at operation, there was no evidence of the free omental graft in two patients. The pedicled omental graft was present and viable in the remaining patient, but did not appear to have vascular communication with the epicardiectomized myocardium.

The cell saver during cardiac surgery: does it save?

Conservation and autotransfusion of autologous blood have been proposed as a means to decrease the homologous blood requirements of cardiac surgery. Use of the Haemonetics Cell Saver System to salvage blood shed in the sterile surgical field resulted in a net saving of 105 +/- 88.7 ml of packed red cells in 20 patients undergoing cardiopulmonary bypass. The system is not a cost-effective way to save blood or decrease homologous blood requirements during routine cardiac operations.

Cardioplegic rearrest: clinical experience with 12 patients

Myocardial damage due to ischemic arrest occurs during aortic unclamping and early reoxygenation (reperfusion injury). Thus, surgeons may be reluctant to reinfuse cardioplegic agents if a second period of aortic cross-clamping is required at the end of cardiopulmonary bypass. Because of technical difficulties, 12 patients underwent two consecutive periods of cardioplegic arrest with an intervening period of reperfusion of the heart. All survived without complications. Myocardial biopsy specimens from three patients revealed some cellular edema. Serial enzyme levels measured postoperatively compared favourably with those of 12 other patients who had sustained a single period of multidose cardioplegic arrest. Postoperative hemodynamic measurements were similar to preoperative values. Although cardioplegic rearrest may appear safe in the human heart, further studies assessing hemodynamics, morphology and metabolism are necessary in order to delineate fully the changes that occur with this method of myocardial preservation.

Is cardioplegic rearrest safe?

In cardiac bypass procedures the use of anoxic arrest or ventricular fibrillation is known to cause severe myocardial damage. The authors have investigated the safety of using cardioplegic rearrest when surgical difficulties are encountered at the end of cardiac bypass procedure after cardioplegic arrest and reperfusion of the myocardium. From their clinical experience with 12 patients and laboratory experience with 13 pigs the authors conclude that although cardioplegic rearrest is not ideal it can be used safely in this situation.

A 25-year experience with the closed method of treatment in 139 patients with mitral stenosis

A 25-year experience with 139 patients undergoing closed mitral commissurotomy is reviewed. The primary indication for closed mitral commissurotomy was mitral stenosis, but 24 patients also had other less important valvular defects. Preoperatively, all patients were in New York Heart Association (NYHA) Functional Class III or IV. Average age was 46 years (range, 18 to 77 years). There were 24 men and 115 women. No further operation after initial closed mitral commissurotomy was required in 68% of the patients (95 patients), and NYHA Functional Classification was improved in 93%. Postoperative complications occurred in 3%, and operative mortality was 2.0%. Follow-up revealed restenosis in 6% of the patients, mitral regurgitation in 14%, complications in 7%, and late deaths in 3%. Reoperation, required in 32% (44 of 139 patients), included a second closed mitral commissurotomy (21 patients), open mitral commissurotomy (3), mitral valve replacement (MVR) (18), and MVR after a second closed mitral commissurotomy (2). Improvement in NYHA classification was found in 82% of these patients. Operative mortality was 9.5% for patients having a second closed mitral commissurotomy and 20% for those having MVR.

Priapism after aortic valve replacement

An unusual case of priapism is described. The cause was unknown but the onset of the condition coincided with the start of Coumadin therapy which was given orally to a 65-year-old man who had undergone aortic valve replacement. Management of this patient was difficult. Conservative measures failed, but a corpus spongiosum--cavernosum shunt successfully resolved the problem. The authors emphasize that priapism must be treated urgently if potency is to be maintained. They also consider the various possible causes and treatment of priapism.

Hypertension after coronary operation. Can it be prevented by pulsatile perfusion?

Nonpulsatile perfusion during cardiopulmonary bypass (CPB) has been implicated as a causative factor of postoperative hypertension. In a consecutive series, patients undergoing coronary bypass were selected for perfusion with either nonpulsatile flow (American Optical roller pump) or pulsatile flow (Desjardin's modification of the roller pump). The incidence of postoperative hypertension and the levels of peripheral renin were noted. No differences could be observed in renin activity, with either modality of perfusion, before CPB, after 30 minutes of stable CPB, or 2 hours postoperatively. Hypertension, necessitating treatment, occurred in 60% of the patients having pulsatile and 68% of those having nonpulsatile perfusion (p less than 0.05). Although pulsatile CPB would appear to be more physiological than nonpulsatile perfusion, this method of creating pulsatile flow does not appear to eliminate postoperative hypertension.

Hemolysis during pulsatile perfusion: clinical evaluation of a new device

The degree of hemolysis occurring during cardiopulmonary bypass was evaluated in two groups of patients undergoing pulsatile and nonpulsatile perfusion. Results indicate that, with a newly developed method of creating pulsatile flow, both groups of patients compared favorably and had approximately the same degree of hemolysis. Because of its simplicity, low cost, reliability, and limited hemolytic activity, this pulsatile device warrants further clinical evaluation.

Inhalation of foreign bodies by children: a continuing challege in management

In a review of 19 years' experience with inhalation of foreign bodies by children the 33 patients (mean age 28 months) were found to have presented most frequently with wheezing or coughing, or both, of recent onset, and to have decreased air entry, rhonchi or respiratory stridor, or a combination of these signs. Eighteen children had inhaled a nut, a pea or a bean. The other 15 had inhaled various organic and inorganic objects. All the children underwent bronchoscopy, and the foreign body was completely removed in 19 during the first procedure; the remainder required repeated bronchoscopy or direct surgical removal of the foreign body, or both. Permanent disability or death was not encountered. The findingsof the study indicate that early bronchoscopic removal is the preferred treatment when a child inhales a foreign body.

Subaortic annular left ventricular aneurysm: an unusual cause of aortic regurgitation

A subaortic left ventricular aneurysm in a 21-year-old white woman is described. The clinical features were those of moderately severe aortic regurgitation, and the chest x-ray film showed cardiac enlargement with a bulge on the left heart border. Angiography confirmed the presence of gross aortic regurgitation and revealed an aneurysm behind the aortic root. At surgery, the aneurysm was found to be located below the aortic valve ring and communicated with the left ventricle through an ostium of 2.5 cm. Aortic valve replacement and closure of the aneurysmal ostium were carried out successfully.

Glucose substrate in myocardial protection

Glucose-insulin-potassium (GIK) was infused preoperatively in 30 patients scheduled for coronary artery operation. Before cardiopulmonary bypass (CPB) each patient received an intravenous infusion of 50% glucose. Myocardial protection was achieved with a cardioplegic solution containing glucose. A similar group of 30 patients received an equal volume of NaCl infused preoperatively and before CPB, and their cardioplegic solution contained no glucose. Clinically and by hemodynamic evaluation postoperatively one could not separate the two groups. Glycogen grading of the myocardium prior to bypass demonstrated no difference in glycogen levels in patients receiving glucose and those receiving NaCl. However, at the end of cardioplegic arrest only the group receiving glucose maintained normal grading of myocardial glycogen.

Prosepctive analysis of heart biopsies in coronary artery surgery

In a prospective analysis of 36 biopsies from human hearts performed at the time of elective coronary operation, several morphological changes were identified in the myocardium. Some of these changes (fibrosis, vacuolation, edema, and amyloid deposition) are of clinical signficance and may affect the long-term prognosis for patients undergoing revascularization procedures. It appears, therefore, that knowledge of the morphological state of the myocardium at the time of operation can prove useful in elucidating further the long-term effects of coronary artery bypass on the left ventricular myocardium.

Intraoperative transmural myocardial biopsy: a simple technique

A Tru-cut disposable biopsy needle was used in 10 pigs, 3 cadavers and 63 humans to obtain transmural ventricular myocardium for diagnostic and research purposes. The technique proved simple and safe. In every case an adequate amount of full-thickness myocardium was obtained which was examined by light and electron microscopy and used for enzyme studies and glycogen measurement.

Prospective analysis of valvular replacement without venting the left ventricle

The present study is a prospective analysis of a series of consecutive valve replacement and combined (valvular plus coronary artery) operations performed without left ventricular decompression. Results indicate that left ventricular venting (direct or indirect) is unnecessary provided that cardioplegic arrest is used, that the venous line is positioned in the right atrium, and that left-sided pressures are monitored. Left ventricular distention, as measured by left ventricular pressure recording, did not occur; air embolism, as determined clinically and by electroencephalographic (EEG) monitoring, was not encountered. The routine use of a left ventricular vent has been abandoned in most intracardiac operations at our center.

Cerebral surveillance during cardiac surgery

There is at present no ideal method for determining the adequacy of cerebral blood flow during nonpulsatile cardiopulmonary bypass procedures. Clinical evaluation of cerebral function while the patient is under general anesthesia may be misleading and unsuspected cerebral damage could result if perfusion of the cerebrovascular bed is inadequate. Electroencephalography appears to be the only reliable noninvasive means of cerebral surveillance during the critical periods of nonpulsatile perfusion.

Is left ventricular decompression necessary during coronary arter surgery?

The use of the "no-vent technique" was studied prospectively in 91 consecutive patients undergoing coronary artery surgery. Analysis of the results indicates that left ventricular distension will not occur if cardioplegic arrest is effected, if the venous line is positioned in the right atrium and if left-sided pressures are monitored. The no-vent technique has shortened the operating time, simplified the pump layout and eliminated the hazards associated with venting.

Arch versus femoral artery perfusion during cardiopulmonary bypass

Aortic arch perfusion is favored by most cardiac surgeons. Perfusion via the femoral artery is still used sporadically at reoperations for aneurysms of the ascending aorta, or for the institution of partial pump support in very sick patients prior to opening of the chest. Our over-all experience indicates that surgical complications occurred primarily in the group of patients perfused via the femoral artery. On the other hand, serious disturbance in cerebral perfusion, as determined by electroencephalogram (EEG) monitoring, occurred in 7 percent of the patients perfused via the arch and 3 percent of those perfused via the femoral artery, a difference that was not statistically significant. We continue to advocate aortic arch cannulation and EEG monitoring during cardiopulmonary bypass procedures.

Monitoring of electroencephalogram during open-heart surgery. A prospective analysis of 118 cases

The electroencephalogram (EEG) was prospectively analyzed in 118 consecutive open-heart procedures. In 96 patients (81%) the records were normal whereas in 22 patients (19%) the EEG showed slow wave activity and decreased electrical voltage. In 16 of these patients the EEG abnormality was transient or only of mild degree. In 10 of this group of patients the abnormality occurred with the institution of total cardiopulmonary bypass (CPB) and returned to normal within 2 minutes. In four other patients the abnormalities were mild, persisted to the end of the CPB, and then returned to normal; in two patients the EEG abnormalities developed in the last half of CPB and then returned to normal. In the remaining six patients the EEG was grossly abnormal. In one of these patients the abnormality was secondary to a previous stroke. In five patients, however, the EEG alerted the surgeon to an otherwise unsuspected poor cerebral blood flow. A serious neurologic insult was probably prevented by identifying and correcting the mechanical cause.

The short saphenous vein: an alternative to the long saphenous vein for aortocoronary bypass

The long saphenous vein and internal mammary artery are considered at present to be the best grafts available for coronary artery bypass. Patients who have had bilateral long saphenous vein stripping and who require multiple aortocoronary bypass grafts present a challenge to the cardiac surgeon. The short saphenous vein appears to be a suitable alterative.

Technique for removal of detached polyethylene catheters from intracardiac chambers and great vessels

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Myocardial glycogen in prevention of perioperative ischemic injury of the heart: a preliminary report

The incidence of arrhythmias, low output and acute myocardial infarction in the perioperative period was analyzed for 119 patients who underwent aortocoronary bypass surgery. The incidence for three groups of patients was as follows: 44% for 72 patients who did not receive glucose-insulin-potassium (GIK) before operation (no-GIK group), 32% for 25 patients who received preoperative GIK alone before operation (GIK group) and zero in 22 patients who received GIK before operation plus a bolus of 50% glucose (0.5 ml/kg body weight) at the beginning of operation (GIK-G group) (the difference between the GIK-G group and the other two groups is significant; P less than 0.001). Determination of myocardial glycogen content of 63 ventricular biopsies revealed a 2+ to 4+ content in 48% of the no-GIK group, 83% of the GIK group and 100% of the GIK-G group (P less than 0.05). The incidence of complications in patients with myocardial glycogen content of 2+ to 4+ was significantly lower (P less than 0.005) than in those with myocardial glycogen content of 1+. Experimentally, myocardial tolerance to ischemic injury parallels myocardial glycogen content. Our preliminary observation that prior administration of GIK-G increases myocardial glycogen content with a concomitant reduction in complications is consistent with these experimental observations.

Ventricular aneurysm and septal defect complicating acute myocardial infarction: early surgical correction

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