Use of a sagittal oscillating saw for repeat sternotomy: a safer and simpler technique

A method of repeat sternotomy using a microsagittal oscillating saw is described. We have found this method to be safer and simpler than previously described techniques. We have used this technique in more than 50 repeat sternotomies without a single complication related to the mediastinal reentry procedure.     

Management of immature teratoma of the ovary in children by conservative resection and chemotherapy

Six patients with immature teratoma of the ovary were treated with surgery and chemotherapy. Surgical management consisted of unilateral salpingooophorectomy, biopsy and conservation of the contralateral ovary, and biopsy of peritoneal implants. Triple-agent chemotherapy with vincristine, actinomycin D, and cyclophosphamide was given to four patients and appeared to be beneficial. Radiation therapy was not employed. Local resection of teratomatous recurrences was frequently necessary. Thorough sampling of this tumor is mandatory for establishment of an exact pathologic diagnosis. All six patients are surviving in good health at 1–8-yr follow-up. The prognosis of immature teratoma in the child or adolescent appears more favorable than previously appreciated.     

Carotid endarterectomy: Is a shunt necessary?

Seventy-seven carotid endarterectomies performed on fifty-nine patients, using induced systemic hypertension during carotid artery clamping, were reviewed. The risk of cerebral ischemia is reduced to a minimum by this technic. The measurement of the internal carotid artery stump pressure is an excellent guideline for the need of additional brain protection. An internal shunt is rarely necessary. Thromboembolic phenomena contributed to the major neurologic complications encountered (two deaths and one stroke). Extreme gentleness and careful surgical technic cannot be overemphasized.     

Pulmonary Valvotomy: An Alternative Method

An alternative technique of pulmonary valvotomy for patients with pulmonary atresia and intact ventricular septum is presented. The method is simpler and safer than open valvotomy with inflow occlusion or with cardiopulmonary bypass. It is more precise and controlled than closed valvotomy.     

Serum Cefazolin Levels during Cardiopulmonary Bypass

This study was done to assess the adequacy of a regimen using cefazolin as a prophylactic antibiotic for patients undergoing open-heart operation. At the time of the preoperative medication, adult patients received 1 gm of cefazolin intramuscularly, and pediatric patients were given a dose of 20 mg per kilogram of body weight. Group I consisted of 10 adults undergoing a variety of cardiac procedures. The mean serum cefazolin level after institution of cardiopulmonary bypass was 27.36 μg/ml (range, 13.1 to 40.3 μg/ml). This level remained fairly stable throughout cardiopulmonary bypass. Group II consisted of 10 pediatric patients undergoing cardiac procedures for repair of a variety of congenital anomalies. The mean serum cefazolin level after institution of cardiopulmonary bypass was 20.01 μg/ml (range, 11.4 to 28.9 μg/ml) and remained stable for the duration of the procedure. In both groups perfusion pressure, urinary output, and body temperature did not seem to have any influence on these levels.It is concluded that the administration of one dose of cefazolin intramuscularly before operation results in an adequate and stable serum cefazolin level in patients undergoing cardiopulmonary bypass for up to three hours, possibly longer.     

Techniques for multiple internal mammary artery bypass grafts

Long-term patency of the internal mammary artery graft surpasses that of all other bypass conduits. The use of multiple internal mammary artery grafts should improve the long-term results following coronary artery bypass grafting. Technical factors used in mobilizing, preparing, and anastomosing the internal mammary artery are discussed in this article. Fifty-three patients received sequential attached left internal mammary artery grafts from April, 1982, to August, 1983. In 6 of these patients, the right internal mammary artery was anastomosed to a circumflex marginal branch. There were no operative deaths or instances of low cardiac output. One patient suffered anastomotic narrowing that possibly could have been prevented by excision of excess tissue from the internal mammary artery pedicle. Multiple internal mammary artery grafting should have a profound influence on the results of coronary artery bypass grafting.     

Bovine carotid artery heterografts versus polytetrafluoroethylene grafts. A prospective, randomized study

A prospective, randomized comparison of BCAH and PTFE vascular access grafts resulted in no statistically significant difference when analyzed for survival rates of complications, types of complications, reasons for failure, and clot salvageability. The results in diabetic patients were similar to those in nondiabetic patients. The majority of retrospective studies and subjective experiences favor PTFE grafts over BCAHs. The explanation may be part that BCAH preceded PTFE grafts into clinical use, and inexperience in the operating room and in the dialysis unit had an effect on BCAH results. A review of impressions of the graft materials indicated a decided preference for PTFE grafts.     

Early surgical intervention in premature infants with respiratory distress and patent ductus arteriosus

Ten premature infants with severe idiopathic respiratory distress syndrome and a large patent ductus arteriosus who underwent ligation are discussed. There were no surgical deaths, but two late deaths occurred. Three similar infants who were not operated on are also presented; all of them died. An additional forty-four such patients with ductus ligation reported on recently were reviewed.Evidence is presented that strongly supports ligation of the ductus as soon as it becomes apparent in infants with severe respirator-dependent idiopathic respiratory distress syndrome.The diagnosis of patent ductus arteriosus is reliably established clinically, and the relatively high complication rate associated with cardiac catheterization in premature infants contraindicates its use.     

Late assessment of results of cricopharyngeal myotomy for cervical dysphagia

Results of surgical section of the cricopharyngeus muscle in the posterior midline for treatment of upper esophageal dysphagia in nineteen patients are presented. Indications included a variety of neuromuscular disorders with or without Zenker's diverticulum. Follow-up study for as long as eight years reveals uniform success of the operation in properly selected patients, particularly as measured by the patients' response. There has been no morbidity or mortality related to the operative procedure.     

Twelve-year experience with bilateral internal mammary artery grafts

A 12 1/2-year experience with 227 patients who underwent coronary revascularization with bilateral internal mammary artery (IMA) and supplemental saphenous vein grafts is presented. There were 725 coronary grafts performed (3.2 per patient). Forty-four IMA grafts were sequential. In 42 patients, the right IMA was placed through the transverse sinus to revascularize the circumflex artery. Operative mortality was 4% (9 of 227 patients). Postoperative complications included sternal infection (4 patients), reexploration for bleeding (5), and diaphragmatic dysfunction (10). Postoperative arteriography in 30 patients (mean interval, 4 1/4 years) revealed that 92% (34/37) of the left IMA and 87% (26/30) of the right IMA grafts were patent. Late follow-up was complete in 207 surviving patients. Eighteen late deaths (9 cardiac and 9 noncardiac) occurred. Actuarial survival was 83% at 10 years after operation. Of 68 patients followed from 8 to 12 1/2 years (mean interval, 10 1/2 years), 69% were asymptomatic, and 28% were in New York Heart Association Functional Class II. We conclude that bilateral IMA grafting can be accomplished with low operative risk and provides excellent long-term results.     

The free internal mammary artery bypass graft. Use of the IMA in the aorta-to-coronary artery position

Transposition of the internal mammary artery (IMA) into the aorta-to-coronary artery position is described, and 4 patients who underwent this operation are reported. Currently, this type of bypass graft is reserved for those patients who have unsuitable or stripped saphenous veins. The free IMA grafts can be connected to any of the major coronary vessels, and in most instances optical assistance is not necessary. There was no significant difference in recorded blood flow between these free grafts and a large group of in situ IMA-to-coronary artery bypass grafts.     

Risks of mitral valve replacement and mitral valve replacement with coronary artery bypass

One hundred thirty consecutive patients who underwent mitral valve replacement (MVR) or MVR with coronary artery bypass grafting (CABG) using cold crystalloid cardioplegic solution were analyzed to determine operative mortality and risk factors. Twenty-eight patients had mitral stenosis (MS), 37 had mitral regurgitation (MR), 37 had mixed MS and MR, 23 had MR with coronary artery disease (CAD), and 5 had MS with CAD. Preoperative pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac index were not different among groups, but patients with MR and CAD had a significantly higher left ventricular end-diastolic pressure (LVEDP) and a significantly lower ejection fraction than other groups. Mortality was 7.1% for patients with MS, 5.4% for MR, 8.1% for mixed MS and MR, 0 for MS with CAD, and 21.7% for MR and CAD. Overall mortality was 9.2%. Eleven patients had emergency operations for cardiogenic shock with a mortality of 45%. Nineteen additional patients in New York Heart Association (NYHA) Functional Class IV had MVR or MVR plus CABG with a mortality of 26%. Sixteen patients required intraaortic balloon pump assistance, and 9 survived. Four patients with MR and CAD required the left ventricular assist device, and 3 survived. Excluding patients who had emergency operations, overall mortality was 5.8%. Excluding patients who had emergency operations and patients in NYHA Functional Class IV, overall mortality was 2%. Factors associated with death were cardiogenic shock, NYHA Class IV, LVEDP greater than 15 mm Hg (16% mortality), and age greater than 60 years (15% mortality).     

Coronary bypass surgery in patients with circulating lupus anticoagulant

Clinical and laboratory experience with circulating lupus anticoagulant in 3 patients undergoing coronary artery bypass procedures is reported. This circulatory anticoagulant inhibits activation of prothrombin by the prothrombin activator complex (factor Xa, factor V, and phospholipid). The presence of lupus anticoagulant was initially detected because of a prolonged activated partial thromboplastin time and a normal or mildly prolonged prothrombin time. The 3 patients underwent uncomplicated coronary artery bypass grafting and experienced no abnormal bleeding postoperatively. The lupus anticoagulant is a rare cause of bleeding after open-heart surgery. It appears to be a problem only when an additional coagulation defect is present.     

Clostridial necrotizing enterocolitis

In a bacteriologic investigation of infants with necrotizing enterocolitis (NEC), 16 of 50 infants had clostridia in cultures of blood or of peritoneal fluid obtained by paracentesis. Twenty-eight of the 50 infants had enteric bacteria other than clostridia, and six infants had sterile cultures. Of the 16 infants with clostridia, nine had C. perfringens and seven had other species of clostridia. Compared to infants with nonclostridial NEC, those with clostridial NEC were larger and more mature, had more extensive pneumatosis intestinalis and gangrene and more rapid progression of NEC. The nine infants with C. perfringens had a fulminant form of NEC, analogous to gas-gangrene of the intestine. Mortality in this group was 78% (7/9). The seven infants with clostridial species other than C. perfringens had a mortality comparable to that of infants with nonclostridial NEC (32%). Improved survival from NEC associated with C. perfringens may be possible only by prevention, rather than earlier diagnosis and improved heroic treatment.     

Technique of internal mammary-to-coronary artery bypass

Experience with 184 patients undergoing internal mammary artery bypass grafting has resulted in a reproducible, simplified, and organized surgical technique. Recatheterization study has been performed in 39 asymptomatic and 3 symptomatic patients at two weeks to one year postoperatively. Two distal stenoses and no closures have been found. The advantages of internal mammary arteries as bypass grafts are that the vessels are comparably sized, there is artery-to-artery anastomosis, only a single distal anastomosis per graft is needed, there is no subintimal hyperplasia, and no leg wound problems occur. Disadvantages are that a more tedious dissection of the relatively more friable internal mammary vessel is necessary, only two grafts are available whereas multiple bypasses are sometimes necessary, and the grafts are limited in length. Complications specific to the procedure are injury to the internal mammary artery during preparation (2 patients) and inadequate graft size (5 patients). Flow rates are adequate to relieve angina. Patients with subclavian bruits or differential blood pressure between the right and left arms are not considered candidates for internal mammary artery bypass grafting. The availability of a special 7-0 Prolene suture on a BV-1 needle and the use of optical magnification are especially important adjuncts to the procedure.     

Controlled Trial of Routine Administration of Platelet Concentrates in Cardiopulmonary Bypass Surgery

Prophylactic administration of platelet concentrates to patients undergoing their first cardiopulmonary bypass operation (coronary artery bypass grafting or uncomplicated valve replacement) was evaluated in a controlled randomized study of 28 patients. Four units of platelet concentrates administered at the end of bypass prevented prolongation of the bleeding time seen in patients not receiving platelets. However, chest tube blood loss, transfusion requirements, and clinical outcome were not improved. Moreover, thrombocytopenia and prolongation of bleeding time did not correlate with blood loss or transfusion needs. Mild thrombocytopenia (to 58,000 platelets per microliter) and transient platelet dysfunction after bypass do not require administration of platelet concentrates, and prophylactic use of this blood component in the surgical setting of bypass is not indicated.     

Intraoperative Use of Nifedipine for Hemodynamic Collapse Due to Coronary Artery Spasm Following Myocardial Revascularization

Sudden hemodynamic collapse in the perioperative period following myocardial revascularization may be due to coronary artery spasm. Nitroglycerin has been the standard treatment for this; however, it is not always effective, and the resultant morbidity and mortality are high. We present the case of a patient in whom sudden hemodynamic collapse due to coronary artery spasm was refractory to intravenously administered nitroglycerin but was relieved quickly with sublingually administered nifedipine. In certain selected patients in whom coronary artery spasm is responsible for myocardial collapse, the drug nifedipine may be effective in relieving this spasm and allowing for myocardial recovery.     

Anomalous origin of the right coronary artery from the pulmonary artery.

Three patients with anomalous origin of the right coronary artery from the pulmonary artery are presented together with a review of the 14 patients with this anomaly previously reported. One of the current patients is the youngest to be diagnosed before operation and the youngest to undergo corrective operation. Although the lesion is usually asymptomatic, it may contribute to sudden death. The only suggestive physical finding is a continuous murmur with diastolic accentuation, which is present only in some patients. There are no diagnostic electrocardiographic or chest roentgenographic changes. Diagnosis is made best by selective left coronary arteriography showing retrograde filling of the right coronary artery from collateral vessels. Operative repair should consist either of direct reimplantation of the proximal right coronary artery into the aortic root or of saphenous vein bypass graft to the coronary artery with ligation of its origin. Operation is recommended when the lesion is recognized.