Late false aneurysm following replacement of ascending aorta: the problem of the teflon graft in combination with a silk suture anastomosis

Two patients underwent resection and replacement of the ascending aorta using a low-porosity Teflon graft anastomosed with silk suture. In both patients false aneurysms developed that required operation 13 and 23 years postoperatively. The clinical courses of these patients, along with data from the literature, suggest that the combination of a low-porosity Teflon graft and a silk suture anastomosis presents a major potential hazard for the development of anastomotic false aneurysm.     

Clinical and Hemodynamic Evaluation of the 19 mm Björk-Shiley Aortic Valve Prosthesis

Between November, 1973, and March, 1980, 43 patients underwent isolated aortic valve replacement with 19 mm Björk-Shiley prostheses at the Johns Hopkins Hospital. There were 4 male and 39 female patients ranging from 12 to 75 years old (mean, 54.5 years). Average weight was 62 ± 2 kg and average body surface area, 1.64 ± 0.3 m². Five patients died within thirty days of operation; however, since 1975, hospital mortality has been 5.9%. The 38 survivors have been followed up for as long as 85 months (mean, 40 months). There were 4 late deaths, and actuarial survival in patients discharged from the hospital was 81% at five years. All long-term survivors were in New York Heart Association Functional Class I (29 patients) or Class II (5 patients). Preoperative and postoperative echocardiograms in 17 patients demonstrated significant decreases in mean left ventricular wall thickness (12.9 ± 1.8 mm vs 10.3 ± 1.4 mm; p < 0.001) and in left ventricular mass (262 ± 95 gm vs 188 ± 50 gm; p < 0.02).Postoperative cardiac catheterization data were obtained from an additional 24 patients undergoing aortic valve replacement with the 19 mm Björk-Shiley prosthesis at the National Heart Institute. Average peak systolic gradient at rest was 16 mm Hg (range, 0 to 45 mm Hg) and was found to be directly related to body surface area (r = 0.60, p < 0.002). Average effective valve orifice area was 1.06 cm² (range, 0.63 to 2.02 cm²).For patients with small aortic roots, aortic valve replacement with the 19 mm Björk-Shiley valve is a satisfactory and, perhaps, preferable alternative to aortic annuloplasty to accommodate larger sized prostheses.     

Diagnosis and Management of Postoperative Pericardial Effusions and Late Cardiac Tamponade Following Open-Heart Surgery

The clinical and laboratory findings of 28 patients identified as having late pericardial effusions were examined. Eleven of these patients were asymptomatic; 9 patients had moderate symptoms including fatigue, malaise, weight gain, and dyspnea on exertion, and 8 patients with similar symptoms had evidence of cardiac tamponade. Ten patients underwent right heart catheterization in the intensive care unit; normal hemodynamics were confirmed in 4 and cardiac tamponade in 6 patients. Pericardiocentesis was effective in decompressing cardiac tamponade in 7 of 8 patients. One patient required operative subxiphoid drainage after unsuccessful pericardiocentesis. In addition, 5 patients with moderate clinical symptoms and pericardial effusions, who did not have cardiac tamponade, underwent pericardiocentesis because of a need for chronic anticoagulant therapy. The remaining patients were managed successfully by observation, discontinuation of warfarin when possible, fluid restriction, and diuretic therapy. All but 1 patient was symptomatically improved. A diagnostic and therapeutic schema is presented as an aid to early recognition of this troublesome and potentially lethal complication.     

Surgical management of lung bud anomalies: lobar emphysema, bronchogenic cyst, cystic adenomatoid malformation, and intralobar pulmonary sequestration.

Recently we saw 9 infants with life-threatening respiratory distress. Four patients had bronchogenic cyst, 2 had cystic adenomatoid malformation, and 9 had congenital lobar emphysema. Another group of 14 older children had recurrent infection and hemodynamic abnormalities, which responded to operative intervention. Each child required an appropriate resection following definitive diagnosis. These lesions represent a spectrum of closely related anomalies that arise during an early stage of embryonic lung bud maturation. Bronchoscopy is rarely useful, but special roentgenographic studies, including perfusion scans and arteriography, are usually diagnostic. Our operative experience is used to emphasize the urgency of precise diagnosis and surgical management of this poorly recognized clinical syndrome.     

The Heparin-coated Vascular Shunt for Thoracic Aortic and Great Vessel Procedures: A Ten-Year Experience

From 1966 to 1976 a flexible, heparin-coated shunt was used for operative procedures on the thoracic aorta and great vessels in 25 patients aged 15 to 78 years. Twenty patients had resection of aneurysms of the descending thoracic aorta. There was 1 death in 15 patients undergoing elective resection and 2 deaths (both from rupturing aneurysms) in 5 patients having emergency resection. The shunt was used in 5 patients who had procedures involving the great vessels.There have been no complications attributable to the shunt in either group. The advantages of this shunt include elimination of the need for systemic heparin, avoidance of hypertension during cross-clamping, and adequate perfusion of the distal circulation without an interposed pump. Because of the ease of handling, low risk, and versatility, we consider the use of this shunt the preferred method for support in elective procedures of the thoracic aorta and great vessels.     

Selective nonoperative management of contained intrathoracic esophageal disruptions.

Eight patients with intrathoracic esophageal disruptions were managed nonoperatively and without pleural drainage. Criteria for nonoperative treatment included the following: disruption contained in the mediastinum or between the mediastinum and visceral lung pleura; drainage of the cavity back into the esophagus; minimal symptoms; and minimal signs of clinical sepsis. Cause of the esophageal perforation was pneumostatic dilatation (1 patient), vomiting (2), and a leak following esophageal operation (5). Antibiotics were administered intravenously to all patients; hyperalimentation was accomplished intravenously in 5, and nasogastric suction was used in only 1. The cavities contracted and the esophageal leaks sealed in all instances. Time before oral intake was resumed ranged from 7 to 38 days (average, 18 days). Days until discharge ranged from 15 to 52 days (average, 28 days).     

A New Instrument for Measurements in Cardiovascular Surgery

An instrument for performing measurements in cardiac and vascular operations is described. This device is a modification of a vascular clamp that provides an accurate and simple method for making intracardiac measurements. The instrument is constructed to provide easy readout of even extremely small measurements.     

Permanent Cardiac Pacemakers in Children: Technical Considerations

Placement of permanent cardiac pacemakers in children presents technical problems that are not encountered in the adult. Problems unique to pacemaker implantation in children are related to the patient's size, the relative bulkiness of pulse generators, the lack of subcutaneous tissue, and the child's growth and long life expectancy. Based on our experience with implantation of 27 permanent cardiac pacemakers in 13 children, we have found that the use of small pulse generators, placement of epicardial leads, insertion of properitoneal pulse generators, and use of rechargeable pacemakers are satisfactory methods in children.     

Mediastinal infection after cardiac surgery

Mediastinitis is an uncommon complication after cardiac surgery; however, its associated morbidity and mortality demand early recognition and emergency therapy. This review is intended to emphasize certain features of the incidence, pathogenesis, and bacteriology of this complication in patients undergoing cardiopulmonary bypass through a median sternotomy. The diagnosis and treatment of mediastinitis after cardiac surgical procedures, as well as methods of prevention, are also reviewed.     

Systemic-Pulmonary Shunts in Neonates and Infants Using Microporous Expanded Polytetrafluoroethylene: Immediate and Late Results

Thirty infants with various types of cyanotic congenital heart disease underwent systemic-pulmonary artery shunts with a microporous polytetrafluoroethylene (PTFE) graft between May, 1976, and July, 1979. Sixteen of them were less than 1 month old, and the average age of the neonates was 5.3 days. There were no operative deaths and 5 hospital deaths, 2 related directly to the shunt. Five patients required early revision of the shunt. Relief from cyanosis was achieved in each patient. Twenty-five patients have been followed up to three and one-half years. There have been 2 late deaths and one late occlusion of the shunt. One patient outgrew the shunt and required secondary shunting procedures. Three of 30 patients have evidenced mild congestive heart failure, which has responded to digitalis. Because of the reliability and excellent late patency of the PTFE prosthesis, we consider it to be superior to a central or Potts shunt for relief from cyanosis in the neonate and infant, and as reliable as a Blalock-Taussig shunt.     

Routine use of autotransfusion following cardiac surgery: experience in 700 patients.

An autotransfusion technique has been developed for collection and reinfusion of shed mediastinal blood. This system has been routinely applied in the postoperative management of 592 consecutive adult and 108 pediatric cardiac surgical patients. Two hundred seventy-one adult patients (46%) and thirty-six pediatric patients (33%) actually received autologous blood. Autotransfusion volume ranged from 50 to 21,350 ml per patient. In 1976 at our institution, homologous transfusion requirements averaged 8.4 +/- 0.7 units per adult patient. During 1978, with the routine use of postoperative autotransfusion, bank blood transfusions were lowered to 4.2 +/- 0.3 units per patient (p less than 0.001). In contrast to perioperative autotransfusion techniques, collection and reinfusion of shed mediastinal blood is particularly useful for intravascular volume replacement in patients with serious postoperative bleeding.     

Improved Exposure of the Mitral Valve in Patients with a Small Left Atrium

A modification of the usual approach to the mitral valve is described and illustrated. This technique employs right atriotomy and interatrial septotomy, which can be easily performed when standard left atriotomy does not provide satisfactory mitral valve exposure. While this modification is not often necessary, it can be helpful in patients with a small left atrium, especially those with a small left atrium and associated left ventricular hypertrophy.     

Reperfusion before Global Ischemic Arrest Improves the Salvage of Infarcting Myocardium

To study the effect of hypothermic global ischemic arrest on an evolving myocardial infarction and of perfusion of the ischemic zone or region at risk before global ischemia, 62 farm pigs underwent 15, 30, or 60 minutes of reversible coronary occlusion. Twenty-eight of these animals served as controls: reflow to the region at risk was established by removal of the coronary occluder without the addition of global ischemia. Another 26 animals had similar periods of coronary occlusion and then were placed on cardiopulmonary bypass; they underwent aortic cross-clamping and cardioplegia-induced global hypothermic arrest for 45 minutes. Eight additional pigs had two hours of reflow to the region at risk after removal of the occluder and before global ischemic arrest. When superimposed on regional ischemia, global ischemia resulted in a 6-fold increase in infarct size after 15 minutes of coronary occlusion (p < 0.05), a 2.2-fold increase after 30 minutes of coronary occlusion (p < 0.05), and no significant increase after 60 minutes of coronary occlusion. Reperfusion prior to global ischemia completely prevented infarct extension with 0.4% less infarction (not significant) in this group versus the controls without global ischemia.These results clearly demonstrate that infarct extension occurring when global ischemia is superimposed on regional ischemia is greatest early in infarct evolution but that reflow to the region at risk before global ischemic arrest prevents the additional infarction. These data suggest that ischemic myocardium must be supplied with oxygen and metabolic substrate prior to global ischemic arrest to obtain maximum myocardial salvage with surgical revascularization.     

Stroke following coronary artery bypass grafting: a ten-year study

To identify possible risk factors for the occurrence of stroke during coronary artery bypass grafting (CABG), the cases of 3,279 consecutive patients having isolated CABG from 1974 to 1983 were reviewed. During this period, the risk of death fell from 3.9% to 2.6%. The stroke rate, however, fell initially but then rose from 0.57% in 1979 to 2.4% in 1983. Adjustment of these data for age clearly demonstrated that the risk of stroke has increased largely because of an increase in the mean age of patients undergoing CABG procedures. A case-control study involving all 56 stroke victims and 112 control patients was used to identify those risk factors significantly associated with the development of stroke in univariate analysis: increased age (63 versus 57 years in stroke patients and controls, respectively; p less than 0.0001); preexisting cerebrovascular disease (20% versus 8%; p less than 0.03); severe atherosclerosis of the ascending aorta (14% versus 3%; p less than 0.005); protracted cardiopulmonary bypass time (122 minutes versus 105 minutes; p less than 0.005); and severe perioperative hypotension (23% versus 4%; p less than 0.0001). Other variables not found to correlate with postoperative stroke included previous myocardial infarction, hypertension, diabetes mellitus, lower extremity vascular disease, preoperative left ventricular function, and intraoperative perfusion techniques. Elderly patients who have preexisting cerebrovascular disease or severe atherosclerosis of the ascending aorta or who require extensive revascularization procedures have a significantly increased risk of postoperative stroke.     

Implantation of the Automatic Defibrillator: The Subxiphoid Approach

The automatic implantable defibrillator is an electronic device capable of diagnosing and correcting malignant venticular arrhythmias. While major thoracic surgery was required in the original 24 implants, a new technique for implanting the device has been developed. The first subxiphoid implantations have been accomplished with the defibrillatory function successfully tested intraoperatively. The advantages and indications of the subxiphoid technique are reviewed.     

Operative intervention for postinfarction angina

Thirty-four patients (26 men and 8 women) underwent myocardial revascularization following myocardial infarction (MI) at the Johns Hopkins Hospital during 1980 through 1982. Average age was 59 years. Of the 33 patients with unstable angina, 61% had ischemia in the infarct zone and 39% had "ischemia at a distance." Mean time from MI to operation was 16 days. The MIs were equally divided between a transmural and a subendocardial location. Eleven patients had a history of congestive heart failure. Intraaortic balloon pumping was used preoperatively for anginal stabilization in 14 patients. Mean ejection fraction for the group was 52%. There were 3 operative deaths, all 3 due to myocardial failure. Late follow-up (mean, 13.7 months; range, 6 to 35 months) is complete for 28 patients. There was 1 late death, secondary to cardiac failure. There were no late MIs. Angina had recurred in 5 patients, but only 2 were taking antianginal medication. At the time of follow-up, 52% of patients were in New York Heart Association Functional Class I. This experience suggests that operative intervention for postinfarction angina can be accomplished with an acceptable mortality and thereby increase survival, reduce the later occurrence of MI, and relieve angina in this high-risk group.     

Acute physiological changes following heart-lung allotransplantation in dogs

The feasibility of clinical heart-lung transplantation requires a better understanding of the physiological consequences of the operation, heart-lung denervation, and the quality of graft preservation. An acute canine model was used to evaluate heart-lung function during the first 24 hours after transplantation. Measurements of cardiopulmonary dynamics were performed in 5 donor animals and compared sequentially after transplantation in the respective recipients. Orthotopic allotransplantation was performed on cardiopulmonary bypass with moderate hypothermia after perfusion of both the heart and lung with a clinical cardioplegic solution (4 degrees C; potassium chloride, 30 mEq/L; mannitol, 20 gm/L). Postoperatively, the animals were ventilated continuously and anesthetized. Hemodynamic variables were monitored, and measurements were made of arterial and venous oxygen, carbon dioxide, saturation, and pulmonary mechanics. Cardiac output and a derived measurement of lung water were determined. Pulmonary vascular resistance, arteriovenous shunt, resistance, and compliance were calculated. At the termination of the experiment, significant differences were observed between donor and recipient lung-water levels (7.7 +/- 0.9 ml/kg versus 12.0 +/- 3.1 ml/kg, respectively; p less than 0.05); 100% arterial oxygen tension (509 +/- 37 mm/Hg versus 227 +/- 114 mm/Hg, respectively; p less than 0.01); and pulmonary compliance (38 +/- 18 ml/cm H2O versus 11 +/- 4 ml/cm H2O, respectively; p less than 0.05). Arteriovenous shunt increased from 12.2 +/- 4 to 16.5 +/- 5% (p = 0.2). This model evaluates the technique currently employed clinically and will be used in the future to compare methods of heart-lung preservation with the goal of allowing distant heart-lung procurement.     

The clinical assessment of selected patients with bronchogenic carcinoma.

This paper describes the clinical management of patients with malignant cells in their sputum and a normal chest roentgenogram and those with asymptomatic peripheral pulmonary masses. The source of malignant cells in the sputum of patients with no roentgenographic abnormalities can be localized by tantalum bronchography and fiberoptic bronchoscopy. Peripheral pulmonary masses can be diagnosed preoperatively by needle biopsy or transbronchial fiberoptic bronchoscopy with little morbidity and no mortality. These procedures are not necessary, however, if there is firm clinical and roentgenographic evidence of malignancy. Bronchogenic carcinomas presenting as asymptomatic circumscribed peripheral pulmonary masses have a 25% incidence of occult mediastinal lymph node metastases. In view of this relatively high incidence of metastasis, we think mediastinoscopy should routinely be performed prior to thoracotomy is asymptomatic patients with a peripheral pulmonary mass and no roentgenographic evidence of mediastinal widening.     

Improved myocardial performance in postoperative cardiac surgical patients with sodium nitroprusside

Myocardial performance in the immediate postoperative period was studied 49 cardiac surgical patients treated with nitroprusside alone. With a thermodilution catheter positioned in the pulmonary artery, cardiac output was calculated and cardiac index, systemic vascular resistance index, and stroke work index were derived before after treatment with nitroprusside. The drug was a administered to all patients because of elevated systemic vascular resistance index. Based on their mean arterial pressure and cardiac index before treatment, the patients fell into two groups. Group I patients (N = 25) had elevated mean arterial pressure and normal cardiac index. Group II patients (N = 24) had normal mean arterial pressure and subnormal cardiac index. Nitroprusside administration resulted in a significant reduction of systemic vascular resistance index in all patients. In Group I the mean arterial pressure was lowered significantly while cardiac index increased only slightly. In Group II there was no change in arterial pressure, but cardiac index improved significantly. The results not only confirm that nitroprusside is effective in managing postoperative hypertension, but also demonstrate that in patients with postoperative left ventricular failure, the drug can improve cardiac output by reducing systemic vascular resistance without significantly lowering arterial blood pressure.     

Surgical management of congenital pulmonary valve dysplasia.

Pulmonary valvular stenosis secondary to congenital valve dysplasia differs markedly from the classic variety of pulmonary stenosis. The reported mortality of patients treated by standard commissurotomy is 38 to 66%. The clinical features and operative management of 14 patients with dysplastic pulmonary valves are reviewed. Three groups of patients were studied. Group 1 consisted of 5 patients treated by commissurotomy. Group 2 comprised 3 patients treated by partial excision of the valve. In neither group were there operative deaths, but 5 of the 8 patients developed recurrent stenosis; 3 required reoperation. In 1975, because of the high incidence of recurrent stenosis, total valvectomy was begun. Ten patients (Group 3) have undergone valvectomy with 1 death. Nine patients were doing well at 3 to 15 months of follow-up. Based on the reported mortality and present findings, total excision of the valve is recommended for relief of stenosis in pulmonary valve dysplasia.