An expanded indication for coronary surgery

In the first 48 hours following open-heart operation, 33 patients in rotation had an infusion of (1) 2 liters of 10% glucose in water, 80 units of regular insulin, and 160 mEq of potassium (GIK), (2) the same solution without insulin (GK), or (3) 5% glucose in water (a control group). The three groups were matched: in each, 8 patients had Functional Class III or IV disease by New York Heart Association criteria, and 8 had valves replaced. Anesthesia and perfusion techniques and supportive care before and after operation were identical in all groups. During infusion, mean arterial levels of the following were significantly lower in the GIK group than in the two other groups: osmolality, sodium, glucose, lactate, fatty acids, and total ketone bodies. Arterial oxygenation, acid-base balance, and pyruvate, growth hormone, calcium, and insulin levels did not differ among groups. Mean plasma potassium levels were the same during infusion in all groups, but 1 patient in the GIK group, 4 in the GK group, and 4 in the control group had ventricular arrhythmias requiring treatment. The only death was in the GK group. For patients with Functional Class III or IV disease, cardiac output (left atrial-to-thoracic aorta dye curve) was significantly higher both days in the GIK group than in the other groups. The GIK solution promoted aerobic carbohydrate metabolism over lipid metabolism, more hemodilution, and better cardiac output than did GK. The GIK solution may be effective in controlling ventricular hyperirritability.     

Current problems in valvular surgery]

Based upon our experiences of 661 valvular operations for these 10 years, we discussed about three major topics in valvular surgery. The first is the current status of valve repair versus replacement. The second is on the changing aspects of patients undergoing valvular surgery. Finally difficult problems in the treatment of infective endocarditis was discussed.     

Combined surgery for valvular and ischemic heart disease

Combined coronary artery bypass (CAB) and valve surgery is one of the most challenging surgical procedures, but the operative results have improved over the years. We discuss several important points in combined surgery. The first point is cardioplegia, which should be perfect in such complex operations. Sufficient antegrade cold blood cardioplegia should be used in combined CAB and mitral valve surgery. Continuous retrograde cardioplegia is required in CAB and aortic valve surgery. The second point is the prosthesis and grafts. A mechanical prosthesis and arterial grafts should be used in younger patients, while a bioprosthesis and vein grafts with a left internal thoracic artery graft should be used in older ones. Finally, the choice of valve repair or replacement must be considered in mitral surgery with CAB. Valve repair is the choice in patients with mitral prolapse due to chordal rupture, because a perfect repair can be achieved using a well-known procedure. In cases in which repair appears difficult, replacement must be carried out as soon as possible. In mitral valve replacement the continuity between the papillary muscles and the mitral ring must be preserved for good left ventricular performance.     

Considerations for revision cervical spine surgery

Elective spine surgery becomes more popular every year. Unfortunately, a significant number of these patients report persistent or recurrent symptoms, and/or develop late sequelae. Revision spinal surgery can be a complex and risky endeavor, and this patient population represents a challenge to spine care teams. Indications for cervical revision surgery can include pseudarthrosis, adjacent segment disease, incomplete decompression, failure of instrumentation, and progressive deformity. Determining whether or not a patient is a candidate for revision surgery is crucial. This chapter reviews the patient evaluation and treatment strategies for conditions that require cervical spine surgery.