Concomitant repair of congenital tracheal stenosis and complex cardiac anomaly in small children

Severe obstructive lesion of the trachea combined with complex congenital cardiac anomaly has generally been regarded as a fatal disease. Herein we report the successful concomitant repair of severe tracheal stenosis and complex cardiac anomaly with the use of cardiopulmonary bypass in two cases. The first patient was a 5-year-old boy with tetralogy of Fallot associated with a localized intrathoracic tracheal stenosis caused by complete cartilaginous rings. Tracheal resection and end-to-end anastomosis combined with total correction of tetralogy of Fallot was performed with the aid of cardiopulmonary bypass. The second patient was a 5-month-old girl with a pulmonary artery sling, scimitar syndrome, and extensive tracheal stenosis. The patient underwent definitive correction of cardiac lesions and complete tracheal reconstruction with a cartilaginous graft with the aid of cardiopulmonary bypass. Utmost care was paid to avoid contamination during the operation. Both of the patients are doing well at present without any signs of complication, 2 years 5 months and 1 year 10 months after the operation, respectively. We advocate concomitant repair of both lesions, with cardiopulmonary bypass, in the surgical managements of infants and small children who have a difficult and otherwise fatal combination of complex congenital cardiac anomaly and severe intrathoracic tracheal stenosis.     

The evaluation of tracheal temperature to monitor core temperature in various operations

Tracheal temperature was evaluated to monitor core temperature during cardiac, upper abdominal and lower abdominal operations. The tracheal temperature was measured by a thermistor attached to the intra-cuff of the tracheal tube. In cardiac surgery, there was a good correlation between tracheal temperature and forehead deep temperature (r = 0.93) before and after cardiopulmonary bypass, and also between tracheal temperature and the temperature of blood from the cardiopulmonary bypass (r = 1.00) during cardiopulmonary bypass. These results indicate that tracheal temperature accurately reflects carotid artery temperature. In upper abdominal operations, the tracheal temperature showed good correlations with forehead core, esophageal, bladder and rectal temperatures (r = 0.81-0.90). On the other hand, bladder and rectal temperatures were different from forehead deep (r = 0.43, 0.55) and tracheal temperatures in lower abdominal operations. These results suggest that the tracheal temperature is valuable to monitor core temperature.     

Traumatic rupture of the innominate artery.

OBJECTIVE: Blunt traumatic rupture of the innominate artery is uncommon. We reviewed our experience to correlate the impact of patient stability, presence of associated injuries and location of the injury within the artery with outcome. METHODS: A retrospective review was performed of patients admitted between January 1, 1998 and December 17, 2002 with traumatic innominate artery rupture. Injuries were defined as proximal if they were 相似文献   

Pulmonary artery balloon counterpulsation for treatment of intraoperative right ventricular failure

Pulmonary artery balloon counterpulsation was used in 3 patients who underwent open-heart operation for the treatment of acquired cardiac lesions. This form of support was initiated because the patients could not be weaned from cardiopulmonary bypass even with intraaortic balloon counterpulsation and maximal pharmacological support. After pulmonary artery balloon pumping was instituted, cardiopulmonary bypass was successfully terminated in all 3 patients. One of them is alive and well one year after operation.     

Rupture of the airways from blunt trauma: treatment of complex injuries.

Tracheobronchial rupture from blunt trauma is usually single and transverse but may be longitudinal or complex, a combination of various sites and forms of rupture. From 1970 to 1990, 183 cases of rupture of the airways were reported in the literature: 136 (74%) transverse, 33 (18%) longitudinal, and 14 (8%) complex. During the same 20 years at Grady Memorial Hospital, 6 patients with such injuries were treated. One had complex injury consisting of rupture of the distal trachea and both main bronchi, 1 had a longitudinal tracheal rupture and rupture of the innominate artery, and 4 had a transverse rupture, 1 of whom also had a traumatic false aneurysm of the left pulmonary artery. Cardiopulmonary bypass was used only for the repair of the complex injury, whereas the repair of the left main bronchial rupture associated with a false aneurysm of the left pulmonary artery was done with standby cardiopulmonary bypass. All 6 patients had satisfactory results from the correction of their lesions except 1 child in whom stenosis developed at the rupture site. This study suggests that complex injuries are rarely seen, and their repair is often quite involved. In some of these cases, the use of cardiopulmonary bypass increases the margin of safety during operation and may encourage repair rather than resection of the affected lung.     

Manubrium-sparing sternotomy and off-pump coronary artery bypass grafting in patients with tracheal stoma

The presence of a tracheal stoma in patients with previous total laryngectomy who require cardiac operations is associated with an increased risk of wound complications and tracheal injuries when a full sternotomy is used. The aim of this report is to describe a technique of manubrium-sparing sternotomy, which can be used in patients undergoing coronary artery bypass grafting without cardiopulmonary bypass.     

Spontaneous coronary artery rupture treated on a beating heart

Primary spontaneous coronary artery rupture (SCAR) without any underlying condition is a rare disorder. The acute and often dramatic nature of hemopericardium with cardiac tamponade advocates immediate pericardial drainage or surgical intervention with timely recognition of coronary artery rupture. This is the first case report of primary SCAR successfully treated on a beating heart without cardiopulmonary bypass.     

Successful use of levosimendan in a patient during cardiopulmonary bypass

Levosimendan (LS) is a novel calcium sensitizer drug that enhances cardiac contractility without increasing myocardial oxygen consumption, and induces vasodilatation. Positive inotropic support is routinely used for weaning from cardiopulmonary bypass circulation in patients with reduced left ventricular function. This case report represents the successful usage of LS for weaning from cardiopulmonary bypass circulation after coronary artery bypass surgery. Levosimendan infusion was started at the sixth hour of cardiopulmonary bypass circulation. There was a dramatic increase in cardiac output 20 minutes after LS infusion, and weaning from cardiopulmonary bypass circulation was achieved. We suggest that LS enhances cardiac performance during and after cardiopulmonary bypass, and can be useful for patients who are unable to be weaned from cardiopulmonary bypass.     

Blunt cardiac rupture in a patient with a history of total correction of tetralogy of Fallot

A 35-year-old man with a history of total correction of tetralogy of Fallot (TOF) fell down while riding a bike and experienced blunt cardiac rupture. His vital signs were stable because the bleeding was limited by an adhesion caused by the previous operation. Chest computed tomography clearly displayed the ruptured points, and an emergency operation was performed. Because a pneumothorax was suspected, a cardiopulmonary bypass was established with a femorofemoral bypass while the patient was conscious before artificial ventilation was initiated. Two ruptured points were detected on the anterior wall of the right ventricle and were repaired by suturing. The patient recovered and was discharged without any major complications 40 days after the operation. This is the first published case of blunt cardiac rupture after total correction of TOF.     

Fractal or biologically variable delivery of cardioplegic solution prevents diastolic dysfunction after cardiopulmonary bypass.

OBJECTIVE: To determine whether myocardial protection is improved by restoring physiologic variability to the cardioplegia pressure signal during cardiopulmonary bypass, we compared cardiac function in pigs in the first hour after either conventional cold-blood cardioplegia (group CC) or computer-controlled biologically variable pulsatile cardioplegia (group BVC). METHODS: Invasive monitors and sonomicrometry crystals were placed, and cardiopulmonary bypass was initiated. The aorta was crossclamped, and cold blood cardioplegic solution was infused intermittently through the aortic root with either conventional cardioplegia (n = 8) or biologically variable pulsatile cardioplegia (n = 8; mean pressure, 75 mm Hg for 85 minutes). The crossclamp was released, cardiac function was restored, and separation from cardiopulmonary bypass was completed. With stable temperature and arterial blood gases, hemodynamics and systolic and diastolic indices were compared at 15, 30, and 60 minutes after cardiopulmonary bypass. RESULTS: Diastolic stiffness doubled from 0.027 +/- 0.016 mm Hg/mm (mean +/- SD) at baseline to 0.055 +/- 0.036 mm Hg/mm (P =.003) at 1 hour after bypass in group CC, associated with increased left ventricular end-diastolic pressure from 9 +/- 2 to 11 +/- 2 mm Hg (P =.001), mean pulmonary artery pressure from 14 +/- 2 to 20 +/- 3 mm Hg (P =.003), and serum lactate levels from 2.0 +/- 0.5 to 5.6 +/- 2.3 mmol/L (P =.008). Systolic function was not affected. In group BVC diastolic stiffness, left ventricular end-diastolic pressure, and pulmonary artery pressure values were not different from control values at any time after bypass, and serum lactate levels were significantly less than with conventional cold blood cardioplegia. Peak pressure variability with biologically variable pulsatile cardioplegia fit a power-law equation (exponent = -3.0; R(2) = 0.97), indicating fractal behavior. CONCLUSION: Diastolic cardiac function is better preserved after cardiopulmonary bypass with biologically variable pulsatile cardioplegia and fractal perfusion. This may be attributed to enhanced microcirculatory perfusion with improved myocardial protection. A model supporting these results is presented.     

Resection of tracheal carcinoma using partial cardiopulmonary bypass--report of a case]

A 43-year-old male was admitted to our hospital with chief complaints of stridor and dyspnea. Bronchoscopy revealed a tumor obstructing almost the whole lumen of the trachea. As it was impossible to insert an endotracheal tube into the distal site of the stenosis in the mediastinum, we used partial cardiopulmonary bypass to maintain gas exchange. The axillary artery and the femoral artery and vein were cannulated for the bypass using local anesthesia. During 105 minutes of bypass, the PaO2 value was good but the PaCO2 value increased up to 70 mmHg. After the trachea was opened, the anesthetic gas was administered across the operative field through the endotracheal tube and the cardiopulmonary bypass was discontinued. Tracheolaryngectomy and permanent tracheostomy with relocation to the right and caudal side of the brachiocephalic artery was performed successfully. The post operative course was very smooth. The patient has been well for 6 months since the surgery. Partial cardiopulmonary bypass proved to be useful for maintaining gas exchange during reconstructive surgery of the trachea. We treated a case of tracheal carcinoma by resection while using partial cardiopulmonary bypass. We believe this is the ninth such case reported Japanese literature.     

Emergency Pulmonary Embolectomy With Percutaneous Cardiopulmonary Bypass

Background. The management of patients with acute pulmonary embolism remains difficult, particularly when cardiogenic shock is involved. The preoperative incidence of cardiac arrest compromises the results of emergency pulmonary embolectomy. In an attempt to reduce the operative mortality rate, we applied percutaneous cardiopulmonary bypass support to restore vital organ perfusion before the surgical intervention.

Methods. Percutaneous cardiopulmonary bypass support was preoperatively instituted in 3 patients with acute cardiopulmonary collapse caused by massive pulmonary embolism. In each patient, cardiac massage and endotracheal intubation were necessary due to loss of consciousness, hypotension, and severe cyanosis. Transesophageal echocardiography was performed to detect any evidence of thrombus in the main pulmonary artery, and each patient underwent the emergency pulmonary embolectomy using conventional cardiopulmonary bypass through a median sternotomy.

Results. Percutaneous cardiopulmonary bypass support immediately provided effective cardiopulmonary resuscitation. Transesophageal echocardiography clearly demonstrated any evidence of thrombus located in the pulmonary artery. Each patient was discharged from the hospital without any postoperative complication.

Conclusions. The use of percutaneous cardiopulmonary bypass support immediately resuscitated and stabilized the cardiopulmonary function and allowed for successful emergency pulmonary embolectomy. In each patient, transesophageal echocardiography was useful for prompt and noninvasive diagnosis.     

Endotoxemia in coronary artery bypass surgery: a comparison of the off-pump technique and conventional cardiopulmonary bypass

OBJECTIVES: The endotoxemia associated with cardiac surgery is thought to be dominantly influenced by the use of cardiopulmonary bypass. The objectives of this study were to assess the relative contribution of cardiopulmonary bypass on endotoxemia apart from cardiac surgical access and to improve our understanding of the potential benefits of off-pump procedures. METHODS: Thirty patients undergoing coronary artery bypass grafting were followed up prospectively. The patients were divided into 2 equal groups: those who underwent bypass grafting through a sternotomy incision without cardiopulmonary bypass (off-pump group) and those who underwent bypass grafting through a sternotomy incision with cardiopulmonary bypass (CPB group). Blood sampling for endotoxin, lactate, and cardiac index measurements were performed during the following time points: (1) after sternotomy; (2) during the coronary occlusion period in the off-pump group and during aortic clamping in the CPB group; (3) after removal of the coronary occlusion sutures in the off-pump group and after removal of the aortic clamp in the CPB group; (4) 30 minutes after the completion of all distal anastomoses in the off-pump group and immediately after weaning from cardiopulmonary bypass in the CPB group; (5) 1 hour postoperatively; and (6) 12 hours postoperatively. RESULTS: Endotoxin and lactate levels were significantly (P <.05) lower in the off-pump group at all sampling time points, except after sternotomy. CONCLUSIONS: In conclusion, this study has shown that endotoxemia during coronary artery bypass surgery seems mainly to be associated with cardiopulmonary bypass procedure. The relatively lower endotoxin levels observed in off-pump surgery might contribute to improved postoperative recovery.     

Cardiopulmonary bypass in conscious patients undergoing cardiac surgery

This study was undertaken to evaluate the feasibility of thoracic epidural anesthesia as an alternative technique to general anesthesia in patients undergoing cardiac surgery under cardiopulmonary bypass. This prospective study was conducted in a tertiary referral hospital. Seventeen patients underwent cardiac surgical procedures requiring cardiopulmonary bypass without general anesthesia under thoracic epidural anesthesia from February to May 2004. An epidural catheter was inserted at any of intervertebral spaces from C7 to T2 on the day before surgery. Subsequently, cardiac surgery was performed under normothermic cardiopulmonary bypass, during which the patients remained conscious. The types of surgery included closure of atrial septal defects, valve replacements, and combined bypass surgery and valve replacements. Approach to the heart was obtained through midsternotomy. Anticoagulation was achieved with 300 units/kg of heparin. Normothermic cardiopulmonary bypass was initiated slowly during the course of 10 to 15 min. Nonpulsatile flow was administered using centrifugal pump and mean perfusion pressure was maintained in the range of 70-80 mmHg. The planned surgical procedure could be performed in all the patients. Soon after establishing cardiopulmonary bypass, the patients developed apnea, which reverted to normalcy a few minutes after disconnection of cardiopulmonary bypass. The mean time for cardiopulmonary bypass was 102 +/- 28 min, aortic cross clamp time was 58 +/- 28 min, and the total duration of surgery was 229 +/- 64 min. None of the patients required conversion to general anesthesia. There was no mortality or morbidity in this series and to our knowledge our series is the first such. Cardiac surgical procedures requiring cardiopulmonary bypass may be conducted under thoracic epidural anesthesia, without endotracheal general anesthesia.     

Surgical management and treatment of a traumatic right atrial rupture

We have treated three patients with blunt traumatic right atrial rupture, all of whom survived after an emergent cardiac repair without cardiopulmonary bypass. Cardiac tamponade was seen in two of the three cases on ultrasonographic cardiography (UCG). The site of rupture was the right atrial appendage in two cases and the superior vena cava-right atrial (SVC-RA) junction in one case. Hemostasis had been obtained at the time of pericardiotomy because of compression by hematoma. Some patients with a right atrial rupture respond to initial volume resuscitation. Suspecting some cardiac injuries in patients with traumatic pericardial effusion on UCG, a patient with a right atrial rupture can survive with a high probability, without the use of cardiopulmonary bypass.     

Effect of cardiopulmonary bypass on pulmonary gas exchange: a prospective randomized study

BACKGROUND: Conventional coronary artery bypass surgery is associated with postoperative pulmonary dysfunction. Inflammation due to cardiopulmonary bypass has been regarded as one of the main causes. In this study, we investigated the effect of coronary revascularization with or without cardiopulmonary bypass on pulmonary function. METHODS: Fifty-two patients (40 male, mean age 60.1 years) were prospectively randomized to undergo coronary revascularization via median sternotomy, with or without normothermic cardiopulmonary bypass. Alveolar-arterial oxygen gradients were measured before and after induction of anesthesia, postoperatively in the intensive care unit during mechanical ventilation and 6 hours after tracheal extubation. The techniques of anesthesia and mechanical ventilation were standardized throughout. RESULTS: Patient characteristics were similar in the two groups. The alveolar-arterial oxygen gradients increased progressively throughout the perioperative period, with no significant differences in the two groups at any time during the study. CONCLUSIONS: Myocardial revascularization with or without cardiopulmonary bypass caused a similar degree of pulmonary dysfunction, as assessed by alveolar-arterial oxygen gradient. Our study suggests that the deterioration in pulmonary gas exchange associated with cardiac surgery is due to factors other than the use of cardiopulmonary bypass.     

Anesthetic management of simultaneous coronary artery bypass grafting and cardiac pheochromocytoma resection under cardiopulmonary bypass

We experienced simultaneous coronary artery bypass grafting and cardiac pheochromocytoma resection under cardiopulmonary bypass in a 79-year-old woman with atherosclerotic angina. During manipulation of the tumor under cardiopulmonary bypass, the serum norepinephrine concentration increased to over seventy times the normal limit, and there was a 25-mmHg rise in mean arterial pressure. Cardiopulmonary bypass has been recommended for the resection of cardiac pheochromocytoma to isolate the heart from the systemic circulation, and thus prevent massive catecholamine release when handling the tumor. However, the serum catecholamine concentration surged in our patient during tumor manipulation under cardiopulmonary bypass, probably because of the reperfused blood from the operating field. We suggest that cardiopulmonary bypass be performed for the anesthetic management of cardiac pheochromocytoma resection, because excessive hypertension can be avoided during cardiopulmonary bypass, even if the catecholamine concentration increases excessively when handling the tumor.     

Clinical outcome after cardiac operations in patients with cirrhosis

BACKGROUND: To evaluate the clinical outcome after cardiac operations in patients with cirrhosis, a retrospective study was undertaken. METHODS: Between 1989 and 2003, 18 patients with cirrhosis who underwent cardiac operations were identified. Their preoperative status and postoperative clinical results were assessed. RESULTS: Ten patients were classified as having Child-Pugh class A cirrhosis, 7 as having class B cirrhosis, and 1 as having class C cirrhosis. Fifteen of 18 patients underwent cardiac surgery using cardiopulmonary bypass, and the remaining 3 patients with class B cirrhosis received coronary artery bypass grafting without cardiopulmonary bypass. In patients undergoing cardiopulmonary bypass, 60% of those with class A cirrhosis and 100% of those with class B cirrhosis and class C cirrhosis had postoperative major complications, including infection, respiratory failure, renal failure, bleeding, and gastrointestinal disorder. One of 3 patients (33%) with class B cirrhosis undergoing coronary artery bypass grafting without cardiopulmonary bypass had major complications. The overall postoperative mortality rate was 17%. Hospital mortality of patients with class A cirrhosis, class B cirrhosis, and class C cirrhosis undergoing cardiopulmonary bypass was 0%, 50%, and 100%, respectively. None of 3 patients with class B cirrhosis undergoing coronary artery bypass grafting without cardiopulmonary bypass died in this study. CONCLUSIONS: Although the incidence of major complications was high, patients with Child-Pugh class A cirrhosis tolerated cardiac surgery satisfactorily. Patients with more advanced cirrhosis, however, may not be suitable for elective cardiac operations with cardiopulmonary bypass. Although our results are not conclusive, coronary artery bypass grafting without cardiopulmonary bypass can be an alternative therapeutic strategy for patients with advanced cirrhosis requiring surgical revascularization.     

Development and clinical application of minimally invasive cardiac surgery using percutaneous cardiopulmonary support.

OBJECTIVES: Optimal cardiopulmonary support during minimally invasive cardiac surgery remains controversial. We developed cardiopulmonary bypass for minimally invasive cardiac surgery using percutaneous peripheral cannulation. METHODS: Subjects were 34 patients (age: 58 +/- 13 years; range: 17-73) undergoing minimally invasive cardiac surgery using percutaneous cardiopulmonary support between June 1997 and March 1999. Procedures included atrial septal defect closure (n = 14), partial atrioventricular septal defect closure (n = 1), mitral valve replacement (n = 8), mitral valve repair (n = 3), aortic valve replacement (n = 6), coronary artery bypass grafting (n = 1), and right atrial myxoma extirpation (n = 1). Bicaval venous drainage from the right internal jugular vein and the femoral vein and arterial return to the femoral artery were instituted by percutaneous cannulation. Venous drainage was implemented by negative pressure (-20 to -40 mmHg) and arterial return was by conventional roller pump. All procedures were conducted through a skin incision 8 +/- 1 cm, from 6 to 10 cm and partial sternotomy. Aortic cross clamping and cardioplegic solution were administered in the surgical field. RESULTS: The operation lasted 224 +/- 45 min., cardiopulmonary bypass 104 +/- 32 min., and aortic clamping 77 +/- 23 min.. No deaths occurred. One patient with residual atrial septal defect required reoperation through the same skin incision. Only 1 patient required homologous blood transfusion. The average postoperative hospital stay was 15 +/- 5 days. CONCLUSIONS: Minimally invasive cardiac surgery using percutaneous cardiopulmonary support is safe and an excellent option for selected patients affected by single valve lesion, simple cardiac anomalies, and coronary artery bypass grafting.     

Surgical trauma affects the proinflammatory status after cardiac surgery to a higher degree than cardiopulmonary bypass

OBJECTIVES: Cytokines contribute to the development of the systemic inflammatory response syndrome or multiple-organ failure frequently observed after cardiopulmonary bypass-supported cardiac surgery. To quantify the contribution of bypass-induced versus trauma-induced inflammatory response after coronary artery bypass grafting, we examined plasma cytokine levels in 120 patients with coronary artery disease who were treated with or without cardiopulmonary bypass-assisted procedures. METHODS: Patients were treated in accordance with one of the following protocols: (1) elective percutaneous coronary intervention without cardiopulmonary bypass (n = 69), (2) cardiopulmonary bypass-supported percutaneous coronary intervention (cardiopulmonary bypass-percutaneous coronary intervention; n = 10), and (3) cardiopulmonary bypass-supported coronary artery bypass grafting (cardiopulmonary bypass-coronary artery bypass grafting; n = 41). Cytokine levels (picograms/milliliter) were measured by enzyme-linked immunosorbent assay from plasma samples obtained at various time points. RESULTS: Interleukin-6 was measured in blood samples from all 3 patient populations. The maximum interleukin-6 level was 13.6 +/- 22.3 pg/mL in the percutaneous coronary intervention group, 170.4 +/- 165.4 pg/mL in the cardiopulmonary bypass-percutaneous coronary intervention group, and 640.3 +/- 285.7 pg/mL in the cardiopulmonary bypass-coronary artery bypass grafting group. Interleukin-6 levels were significantly different, and the 95% confidence intervals did not overlap. In the cardiopulmonary bypass-percutaneous coronary intervention group, bypass duration correlated well with interleukin-6 production ( r = 0.915; P < .001), whereas these parameters did not correlate in patients who underwent cardiopulmonary bypass-coronary artery bypass grafting ( r = 0.307; P = .054). CONCLUSIONS: These findings support the suggestion that surgical trauma and cardiopulmonary bypass contribute to the inflammatory response after cardiac surgery, although trauma may contribute to a higher degree.