False Aneurysm of the Pulmonary Artery: A Complication of Pulmonary Artery Catheterization

A case of Swan-Ganz catheter–induced pulmonary artery injury is discussed. Iatrogenic pulmonary artery injury probably occurs more frequently than is clinically suspected. Pulmonary angiography is urged when hemoptysis occurs in a patient with an indwelling pulmonary artery catheter.     

Pulmonary Artery Sling

A case of pulmonary artery sling in a 1-year-old boy, treated by resection of the left pulmonary artery (LPA) at its origin from the right pulmonary artery (RPA) and reanastomosis of the LPA to the main pulmonary artery (MPA), is reported. In this patient the LPA-MPA anastomosis was demonstrated to be patent in a follow-up pulmonary angiogram six months after the operation. Pulmonary artery sling should be kept in mind when assessing respiratory distress syndrome in children.     

Internal Mammary Artery Cannulation

A technique of internal mammary artery cannulation is described. This approach offers a safe method for arterial monitoring in infants undergoing thoracotomy for palliative cardiac procedures.     

Intraoperative Doppler Coronary Artery Finder

Time-consuming difficulty is occasionally encountered in finding coronary arteries or previously placed vascular grafts during coronary revascularization procedures. A catheter-tipped, continuous-wave Doppler ultrasonic probe with simple audio output has been shown to be capable of expediting the search for these vessels.     

Simultaneous Repair of Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery and Mitral Regurgitation

A 20-month-old boy with anomalous origin of the left coronary artery from the pulmonary artery was successfully treated by combining aortic implantation of the left coronary artery and simultaneous mitral valve replacement. We describe our operative technique and emphasize that in the definitive treatment of this anomaly, it is advisable to not only correct the malformation but also repair the mitral valve damage caused by secondary changes due to infarction.     

Hyperlipoproteinemia as a Significant Risk Factor for Pulmonary Embolism in Patients Undergoing Coronary Artery Bypass Grafting

A five-year (1975 through 1979) retrospective analysis of all cardiac surgical patients who sustained a postoperative pulmonary embolism was undertaken, and lipoprotein profiles of these patients were evaluated. Twenty-six patients (20 men and 6 women) were identified who had definite clinical, laboratory, and radiological evidence of pulmonary embolism in the postoperative period. Twenty had undergone coronary artery bypass grafting, and the remaining 6 had undergone other cardiac surgical procedures. Of the 20 patients who had coronary bypass, 19 (95%) were found to have hyperlipoproteinemia (14 patients with type II and 5 with type IV).There were 4 hospital deaths (15%), all related to pulmonary embolism. The 4 patients had undergone coronary bypass procedures, and all had type II hyperlipoproteinemia. Since patients with hyperlipoproteinemia made up less than 10% of the coronary bypass population, the incidence of pulmonary embolism in this group is highly significant (p < 0.001). Experimental evidence has shown that patients with hyperlipoproteinemia, especially type II, have increased platelet adhesiveness and aggregation, and coagulation abnormalities consistent with a hypercoagulable state. This retrospective study clinically confirms that finding and suggests that early postoperative anticoagulation therapy may be indicated in patients with hyperlipoproteinemia, particularly type II, to reduce thromboembolic complications.     

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.     

Myocardial Revascularization of the Canine Circumflex Coronary Artery Using Retrograde Internal Mammary Artery Flow Without Cardiopulmonary Bypass

A new surgical technique using perfusion of the circumflex coronary artery with retrograde blood flow of the internal mammary artery (IMA) is described. This project was undertaken because the IMA is uniquely well supplied with blood: proximally through its attachment to the subclavian artery, along the sternum by the intercostal arteries to the aorta, and distally from the iliac artery by the epigastric and musculophrenic arteries.In this experimental study, the IMA in 16 dogs was ligated and divided at the subclavian artery, then dissected free down along the sternum to obtain sufficient length. The large subclavian end was then anastomosed to the circumflex coronary artery using a metal cannula technique to perfuse the circumflex bed while the anastomosis was being done. In all 16 dogs, the retrograde flow of the IMA was adequate to maintain the circumflex bed. It is postulated that this technique may have some limited use in man.     

Simple Method for Teaching Coronary Artery Surgery

This simple bench model facilitates the development of technical skills in coronary artery surgery and permits unlimited practice of the maneuvers involved.     

Combined Valve and Coronary Artery Surgery

From 1970 to 1978, 79 patients (Group 1) underwent combined valve replacement and coronary bypass operation. They were compared with 79 consecutive subsequent patients (Group 2) undergoing similar valve replacement. In Group 1, 73% were men compared with 48% in Group 2. The average age in Group 1 was 60 years (range, 42 to 84 years) and in Group 2, 57 years (range, 29 to 74 years). When the patients were first seen, angina was present in 49% in Group 1 and only 24% in Group 2. More than 95% of the patients in both groups were in New York Heart Association Functional Class III or IV. Areas of abnormal contraction were twice as frequent in the angiograms of patients in Group 1 (43%). Thirty-three mitral, 44 aortic, and 2 aortic plus mitral valve replacements were performed in each group. One to 4 grafts were placed in each patient in Group 1, and most had single or double grafts. Early morbidity was more frequent in Group 1. Early mortality was 5 to 6% in each group. Late mortality (average, 3.5 years after operation) was 16 to 17% in each group. The working status and Functional Classification at follow-up were similar for patients in both groups. Combined valve and coronary operation carried a similar operative risk and had similar late results as valve replacement alone.     

Coronary Artery Injury by a Valved External Conduit

A 4-month-old infant underwent repair of type I truncus arteriosus and died immediately after as a consequence of left main coronary artery compression by the metallic stent in the Dacron conduit. To avoid injury to the coronary vasculature, the future location of the porcine valve ring should be assessed and relocated if necessary.     

A Technique of Anastomosis of the Right Internal Mammary Artery to the Circumflex Artery and Its Branches

A new technique for direct revascularization of the left circumflex artery and its ventricular branches through anastomosis with the right internal mammary artery (RIMA) was applied in 56 patients. Postoperative angiographic studies in 17 patients showed that positioned behind the aorta, the RIMA can reach the circumflex artery with no tension, allowing adequate distal filling.     

Pseudoaneurysm of the Thoracic Aorta: A Late Complication of Umbilical Artery Catheterization

Pseudoaneurysm of the thoracic aorta developed in an infant eight months following neonatal catheterization of the umbilical artery. Infection and placement of a stiff polyvinyl chloride catheter in the thoracic aorta appear to be the etiological factors. Preoperative diagnosis was posterior mediastinal tumor, and pseudoaneurysm was not included in the differential. Dacron graft patch angioplasty repair using partial cardiopulmonary bypass was successful. Postoperatively the patient has done well with no pressure gradient. Pseudoaneurysm should be suspected whenever a mediastinal mass appears in children who have had thoracic placement of umbilical artery catheters.     

Reoperation for Coronary Artery Disease

Forty-two reoperations for myocardial revascularization were done in 40 patients. Seventeen of them (1%) are from our series of 1,700 patients. Average number of grafts per patient was 2.27. Complications occurred in 20 patients. There was no operative or hospital (30-day) mortality. Patients classified as improved or asymptomatic constitute 82.5% of the series. Reoperations within one year were done predominantly for technical cause of failure, whereas reoperations done after more than one year were usually for disease progression. The operative technique is described as are maneuvers to help make a reoperation less hazardous. Reoperations have been accomplished relatively safely with results similar to those of initial operation.