Infected Endocardial Pacemaker Electrodes: Successful Open Intracardiac Removal

The long-term results after open intracardiac removal of infected pacing electrodes are presented. Methods: between 1985 and 1990 open intracardiac removal of 19 infected pacing electrodes was performed in seven patients (six male and one femalel, with a mean age of 56 years. The indications were; persisting bacteremia in three; generator pocket infection in four; endocarditis in one; and ventricular tachycardia caused by retracted electrodes in one. All electrodes were fixed in the right heart and extraction by closed methods failed. Percutaneous catheter techniques were not applied in these seven patients. In five patients two ventricular electrodes had to be removed, and in two patients a single one. A total of seven atrial electrodes were removed in six patients (one electrode each in five patients; two electrodes in one patient). All atrial and two ventricular electrodes could be removed through a pursestring suture without use of a pump oxygenator. For the removal of ten ventricular electrodes in six patients (two electrodes each in four patients; 1 electrode each in two patients) a right-sided atriotomy was necessary with cardiopulmonary bypass (CPB). Simultaneously, five new pacing systems were implanted. Results; there were no early or late mortalities. In January 1991, all seven patients are alive and in a mean New York Heart Association Class 1,3 of heart failure after a mean interval of 33 months. In all cases the infection could be controlled with a simultaneous antimicrobial chemotherapy and the postoperative period was free of major complications. Conclusion; open intracardiac removal of retained pacing electrodes with or without use of CPB is a safe procedure without major complications. It is mandatory for all infected pacing electrodes that cannot be extracted by closed methods.     

Predictability of aortic dissection as a function of aortic diameter

The role of aortic diameter on the occurrence of type A dissectionwas investigated in 73 patients with dilated ascending aortaat the lime of pre-operative evaluation. Using transthoracicechocardiography for diagnosis and measurements, 54 patientswere identified with type A dissection (group 1) and 19 withoutdissection (group 2). The true mean aortic diameters were identical(6·0±1·3 cm in group 1 and 6·4±1·4cm in group 2; mean±SD; ns) as were the indexed aorticdiameters (ratio of diameter/body surface area; 3·2±0·8cm . m^–12 and 3·4±0·7cm m^–2respectively; ns). However, the individual diameters showeda pronounced scatter in both groups (range from 3·6±11·0cm). Of the 73 patients, 66 had surgery (47/54 with and 19/19without dissection) and seven patients were treated medically.Emergency surgery was performed in 45/66 patients (all withacute type A dissection) andelective repair in 21/66 (19 withoutand two with chronic type A dissection). In-hospital mortalitywas 18% in the emergency group, 5% in the elective group and57% in the medical group. It is concluded that patients with dilated ascending aorta havea substantial incidence of acute dissection. Their clinicalcourse is unpredictable; acute dissection occurs in some, andin others the ascending aorta continues to enlarge without dissection.Because patients with dissection often arrive too late for electiverepair andhave to be operated on as emergencies with a higheroperative risk, we recommend elective surgery before the diameterof the ascending aorta has reached 6 cm.     

Predictability of aortic dissection as a function of aortic diameter

The role of aortic diameter on the occurrence of type A dissectionwas investigated in 73 patients with dilated ascending aortaat the lime of pre-operative evaluation. Using transthoracicechocardiography for diagnosis and measurements, 54 patientswere identified with type A dissection (group 1) and 19 withoutdissection (group 2). The true mean aortic diameters were identical(6·0±1·3 cm in group 1 and 6·4±1·4cm in group 2; mean±SD; ns) as were the indexed aorticdiameters (ratio of diameter/body surface area; 3·2±0·8cm . m^–12 and 3·4±0·7cm m^–2respectively; ns). However, the individual diameters showeda pronounced scatter in both groups (range from 3·6±11·0cm). Of the 73 patients, 66 had surgery (47/54 with and 19/19without dissection) and seven patients were treated medically.Emergency surgery was performed in 45/66 patients (all withacute type A dissection) andelective repair in 21/66 (19 withoutand two with chronic type A dissection). In-hospital mortalitywas 18% in the emergency group, 5% in the elective group and57% in the medical group. It is concluded that patients with dilated ascending aorta havea substantial incidence of acute dissection. Their clinicalcourse is unpredictable; acute dissection occurs in some, andin others the ascending aorta continues to enlarge without dissection.Because patients with dissection often arrive too late for electiverepair andhave to be operated on as emergencies with a higheroperative risk, we recommend elective surgery before the diameterof the ascending aorta has reached 6 cm.     

Indications for Pericardial Glutaraldehyde-Preserved Xenograft in Repair of Congenital Heart Disease

A glutaraldehyde-preserved equine pericardial xenograft was implanted in 370 patients between 1981 and 1987; pericardial sac closure in 320 (mainly over Dacron implants), atrial repairs in 19, arterial reconstructions in 22 (right outflow tract in 19, Konno's procedure in three), control of bleeding after surgery for thoracic aneurysms in seven, control of plasma leaking PTFE graft in one, and repair of diaphragmal agenesia in one. Overall infection rate was 3/370 (0.8%). Epicardial adhesions (12) at reoperation for orthotopical implants were graded 1.3 +/- 0.9 on a scale of 6 (0 = no adhesions, 5 = calcified or ossified adhesions) after 4 +/- 2 months. Shrinkage of xenograft occurred in 3/19 (16%) atrial repairs and lesser degree aneurysmal dilatation appeared in 1/19 (5%) reconstructions of the right outflow tract. No complications occurred in the implants without direct exposure to the blood stream. We recommend pericardial xenograft for Konno's procedure and control of bleeding. It should not be used routinely in the low pressure side.