A method of outflow tract reconstruction in tetralogy of Fallot with anomalous anterior descending coronary artery.

An anomalous anterior descending coronary artery that arises from the right coronary and crosses the right ventricle outflow tract can compromise corrective operations for tetralogy of Fallot. The only safe method of outflow tract reconstruction reported until now is the use of a tubular graft from the right ventricle to the pulmonary artery. We report successful reconstruction of the outflow tract by placing a standard fabric path under the mobilized anomalous coronary artery. This technique should avoid the late complications of tubular conduits by preserving the natural posterior wall of the outflow tract for growth.     

Noncoronary Collateral Distribution in Coronary Artery Disease

Noncoronary collateral flow is a potential hazard when cold cardioplegia is used for myocardial protection. In this study, noncoronary collateral flow was observed during coronary revascularization in 58 patients. It was distributed significantly (p < 0.005) toward arteries demonstrating intercoronary collateral flow angiographically—10 of 35 with and 12 of 121 without. Preponderance of coronary collateral flow in hearts with more extensive disease may complicate cardioplegic myocardial protection for such patients.     

The effect of the route of administration of Bacillus Calmette-Guerin on regional immunity

In conclusion, under the conditions of the study, oral BCG caused a significant immunopotentiating effect in mesenteric lymph nodes. During the time period studied, the response was regional. However, the most consistent immunopotentiating effect was that shown by the hind-limb injection of BCG. Although there was a more significant regional response from hind-limb injection, there was also a definite tendency toward systemic immunopotentiation. Intraperitoneal BCG did not produce consistent immunopotentiation.     

Simplified insertion of left atrial pressure monitoring catheter

A simplified, safe, and reliable technique is described for intraoperative insertion of a left atrial monitoring catheter using modified, currently marketed plastic intravenous catheters.     

Ventricular venting during coronary revascularization: assessment of benefit by intraoperative ventricular function curves.

Although the physiological benefits of left ventricular venting during cardiopulmonary bypass have been documented experimentally, air embolus is still a concern clinically, and surgeons, therefore, continue to debate whether or not to vent routinely during coronary revascularization. In this study, 10 patients vented during revascularization and 10 not vented were studied immediately before and after cardiopulmonary bypass using Sarnoff ventricular function curves to assess changes in ventricular performance. Stroke work index by each patient before and after bypass was compared at common left atrial pressures and concomitant similar systemic resistances. In patients who were vented, there was overall no change in function (98 +/- 7% of control; range, 146--73%). In patients who were not vented, there was overall significant depression of function (67 +/- 5% of control; range, 91--45%, p less than 0.01). The overall absence of depression in patients who were vented, several of whom had very poor ventricles before bypass, strongly supports venting for coronary revascularization.     

Direct Ascending Aortic Insertion of the “Percutaneous” Intraaortic Balloon Catheter in the Open Chest: Advantages and Precautions

When intraoperative balloon pump support is needed for patients who cannot be weaned from cardiopulmonary bypass and when the balloon catheter will not pass retrograde into the aorta from the femoral artery, the catheter must be inserted into the ascending aorta directly. We have found that the new Datascope “percutaneous” balloon catheter offers many advantages for direct insertion into the ascending aorta, but certain precautions are necessary to prevent cerebral emboli when the percutaneous balloon catheter is used this way.     

Technical considerations in saphenous vein bypass grafts to the right coronary artery.

Measurement of the proper length for saphenous vein bypass grafts to the right coronary artery can be complicated by the increase in cardiac volume that takes place when extracorporeal circulation is discontinued. Inadequate or excessive allowance for this increase can cause undue tension on the grafts or troublesome kinking. This report describes an improved method of orienting vein bypass grafts to the right coronary artery which eliminates problems of incorrect measurement.     

Avoidance of blood transfusion in coronary artery surgery: a trial of hydroxyethyl starch

Banked blood transfusion, with its attendant hazards, may be avoided in certain instances. A search for an acceptable plasma substitute was made. A randomized prospective trial of hydroxyethyl starch (HES) versus plasma for postoperative volume replacement is described. Ninety patients undergoing operations for coronary artery disease were studied over a six-month period. Ten received banked blood in the immediate postoperative period and were excluded from the study. The remaining 80 were randomized into two groups. Group 1 received plasma, and Group 2 received HES. All patients initially had autologous blood transfusion, and in 7 patients this sufficed; these patients were excluded from the study except for regression analysis. Postoperative blood loss and urine output did not differ between groups, but Group 2 patients required significantly more volume replacement (p less than 0.02). In a total of 27 patients drawn from both groups, coagulation factors and colloid osmotic pressure were investigated. There were no significant differences in fibrinogen titer and prothrombin time between groups, but return to normal values was significantly delayed in the HES group (p less than 0.01). Activated clotting time and partial thromboplastin time were unaffected. Colloid osmotic pressure was significantly higher at one week in the HES group (p less than 0.001) and was correlated with the volume of HES given (r = 0.525; p less than 0.01). There were no untoward effects attributable to HES. It is concluded that HES is a safe, cheap, and effective plasma substitute for volume replacement following cardiac surgical procedures.     

Management of sudden coronary death.

Twenty-three survivors of out-of-hospital sudden coronary death (SCD) have been followed subsequent to initial hospitalization, cardiac catheterization and coronary angiography, and ultimate coronary revascularization (11 patients) or medical treatment (12 patients). All were treated at the Milwaukee County Medical Center. History of previous myocardial infarction (10 patients) and predominance of triple coronary artery disease (20 patients) with associated ventricular dysfunction (21 patients) demonstrated advanced coronary disease in both groups. Selection for revascularization (mean, 3 grafts per patient) was not randomized, but was based on precarious coronary anatomy and was reinforced by post-SCD ventricular dysrhythmias and angina. During an average follow-up of 13 months, there were 2 perioperative surgical deaths (1 recurrent SCD) and 3 medical deaths (2 recurrent SCDs), giving a mortality rate of 22%. This is an improvement over reported post-SCD natural history and may support a policy of offering revascularization to all SCD patients who have precarious coronary anatomy.     

Noncardiogenic Pulmonary Edema and Peripheral Vascular Collapse Following Cardiopulmonary Bypass: Rare Protamine Reaction?

Four instances of severe anaphylactoid reaction occurring subsequent to cardiopulmonary bypass are described. These catastrophic reactions, from which 2 patients died, took place approximately an hour following administration of protamine and were characterized by marked peripheral vasodilatation, loss of capillary membrane integrity, and fulminant noncardiogenic pulmonary edema. Primary cardiac depression was not evident. We hypothesize that protamine was the causative agent in these unusually severe reactions. Differential diagnosis from other causes of acute cardiorespiratory dysfunction depended on early assessment of pulmonary artery and left ventricular filling pressures, cardiac output, respiratory mechanics, and arterial blood gases. Therapy was difficult; success in 1 of the patients seemed to have been effected in part by prompt administration of high-dose corticosteroids and maintenance of peripheral vascular tone with an alpha-adrenergic agonist.