Ventricular aneurysmectomy. A 25-year experience.

OBJECTIVE: This study determined predictors of operative survival and improved long-term outcomes in patients undergoing ventricular aneurysmectomy. SUMMARY BACKGROUND DATA: Since the first successful repair of ventricular aneurysm in 1958, refined technique and improvement in perioperative care have been introduced to lower morbidity and mortality. METHODS: The authors reviewed their institutional experience from 1968 through 1993 in treating 523 patients who underwent ventricular aneurysmectomy. RESULTS: Overall operative mortality was 8% and overall median survival was 128 months. Contractility grade, age, and year of operation were predictors of operative mortality and of improved long-term survival. Type of aneurysm repair was not a strong predictor of operative mortality or improved long-term survival. CONCLUSIONS: Ventricular aneurysmectomy can be performed safely using one of a number of established techniques, although operative mortality and long-term survival may not depend on the techniques used.

Videothoracoscopy: improved technique and expanded indications.

Current videoendoscopic technology and percutaneous techniques of exposure and dissection have been successfully applied to abdominal surgery with favorable results. Application of this technology to our practice of thoracoscopy is the basis of this report. Videothoracoscopy has been performed in 39 patients for the following indications: chronic pleural effusion, interstitial lung disease, mediastinal lymphadenopathy in lung cancer, persistent air leak after decortication, mediastinal mass, recurrent spontaneous pneumothorax, hydropneumothorax with persistent air leak, and pleural-based mass. The technique we employ includes lateral decubitus positioning and double-lumen endotracheal intubation with ipsilateral lung collapse. The videoscope, retractors, and instruments are introduced through separate 10-mm incisions. Percutaneous manipulation of instruments and the videoscope is guided by images produced on television screens without dissection, and if resection is performed, the incision is enlarged to allow specimen retrieval. Procedures performed using this technique include pleural biopsy, partial pleurectomy, lysis of adhesions, lung biopsies, staging lymph node biopsy, lung nodule biopsy, pleural-based mass resection, and mediastinal mass biopsy and resection. This videoendoscopic technique greatly improves visualization of thoracic anatomy, facilitating thoracoscopy and enhancing exploration of the chest. It is preferred over conventional thoracoscopy and, in some patients, reduces the magnitude of operation by avoiding thoracotomy.

Prophylaxis of atrial fibrillation with magnesium sulfate after coronary artery bypass grafting.

Ninety-nine consecutive consenting patients were prospectively entered into a randomized, double-blind, placebo-controlled trial to determine the efficacy of postoperative magnesium therapy on the incidence of cardiac arrhythmias after elective coronary artery bypass grafting. No patient had documented or suspected arrhythmias preoperatively. Forty-nine patients received 178 mEq of magnesium given over the first 4 postoperative days, and 50 patients received only placebo. The clinical characteristics of both groups were similar. The preoperative mean serum magnesium concentration was similar in both study (1.90 mEq/L) and placebo (1.90 mEq/L) groups. The mean postoperative serum magnesium concentration in study patients was significantly elevated over postoperative days 1 through 4 when compared with preoperative levels (p less than 0.001). The postoperative mean serum magnesium concentration in control patients declined and remained significantly depressed through postoperative day 3 (p less than 0.001), but increased to preoperative levels by postoperative day 4. The mean serum magnesium concentration was significantly greater in the study patients as compared with the control patients over postoperative days 1 through 4 (p less than 0.001). Although there was no significant difference between groups with respect to episodes of ventricular arrhythmias, there was a significant decrease in the number of episodes of atrial fibrillation in the group receiving magnesium therapy (p less than 0.02). There were no recognized adverse effects of magnesium therapy. Prophylactic magnesium administration seems to lessen the incidence and severity of atrial fibrillation after coronary artery bypass grafting.

Internal mammary artery graft at reoperation: risks, benefits, and methods of preservation.

To determine the effect of a prior internal mammary artery (IMA) graft on coronary artery bypass reoperation (CABR), we reviewed our experience with 410 consecutive patients: 313 received only saphenous vein grafts at initial coronary artery bypass grafting (CABG), and 97 received at least one IMA graft at CABG. Cardiac catheterization data before CABG were available in 110 patients (56 received only saphenous vein grafts, 54 received at least one IMA graft), allowing comparison of left ventricular function at CABG and CABR. Injury of the IMA graft occurred in 5 patients (1 death), but presence of an IMA graft was not an independent predictor of morbidity or mortality. Overall, the incidences of complications and deaths were higher in patients with saphenous vein grafts than in patients with IMA grafts, though not significantly so. Internal mammary artery grafts better preserved cardiac function: patients with IMA grafts had worse left ventricular function before CABG but better left ventricular function before CABR than patients with saphenous vein grafts. Left ventricular function deterioration from before CABG to before CABR was significantly less in patients with IMA grafts. We conclude that the risk of CABR is not increased by a previously constructed IMA graft and that left ventricular function is better preserved at CABR when an IMA graft was constructed at the initial operation.

Efficacy of cefazolin, cefamandole, and gentamicin as prophylactic agents in cardiac surgery. Results of a prospective, randomized, double-blind trial in 1030 patients.

In an effort to develop an improved regimen of antibiotic prophylaxis in cardiac surgery, 1030 patients who were to have elective cardiothoracic surgery involving a median sternotomy were selected at random to receive cefamandole or cefazolin, with or without gentamicin, in a prospective double-blind study. Cefazolin was significantly less effective than cefamandole at both the sternal (1.8% vs. 0.4%, respectively, p less than 0.05) and donor sites (1.3% vs. 0%, respectively, p less than 0.02). Seven Staphylococcus aureus infections occurred among cefazolin recipients as compared with no such infections among the patients receiving cefamandole (p less than 0.01). All five wound infections yielding fungi or gentamicin-resistant gram-negative rods occurred in patients who had received gentamicin as a second prophylactic agent. These data suggest that gentamicin has no role as a prophylactic antibiotic in cardiac surgery and that, compared with cefamandole, cefazolin offers unreliable prophylaxis against deep infection at both the sternal and donor sites.

Internal mammary artery grafts: technical factors influencing patency.

Eight hundred fourteen patients with internal mammary artery (IMA) coronary artery bypass grafts have been restudied 961 times with coronary arteriography, primarily to evaluate the patency of the grafts in the setting of symptomatic coronary occlusive disease. Their records were reviewed to assess graft patency as related to the technical aspects of coronary artery bypass surgery. Patency was evaluated using life-table analysis of the data. The method of harvesting the IMA played no role in patency. The left anterior descending coronary artery was the recipient coronary artery with the highest patency rate. The left IMA had a significantly higher patency rate than the right IMA. As a group, the IMAs had a significantly higher patency rate than saphenous vein grafts. However, there was no difference between right IMA grafts and saphenous vein grafts. The mammary artery grafts that remained patent throughout the study had a significantly higher blood flow after bypass than did those that became occluded (43.0 +/- 0.9 versus 28.9 +/- 1.8 ml/min; p less than .001).

Cryoprecipitate-topical thrombin glue. Initial experience in patients undergoing cardiac operations.

The use of fibrin glues as topical hemostatic agents is reported in the European literature. We have composed an analogous compound in our operating rooms using cryoprecipitate and topical thrombin (1000 units/ml) in equal volumes applied directly to the bleeding site. We have used cryoprecipitate-topical thrombin glue in 26 patients undergoing cardiac operations. Severe bleeding not responding to usual methods of control was encountered during or after coronary artery bypass (n = 17), valve replacement (n = 3), bypass plus valve replacement (n = 5), or repair of postinfarction ventricular septal defect (n = 1). Five patients were operated on emergently and four were undergoing their second cardiac operation. The glue was used in four patients while on bypass and fully heparinized and in 17 patients who continued to bleed after separation from bypass and administration of protamine. Hemostasis was achieved in all patients and none required reexploration for bleeding. In five patients undergoing reexploration for postoperative hemorrhage (none having received cryoprecipitate-topical thrombin glue during the initial operation), the glue provided hemostasis when other measures failed, and no additional reexplorations were needed. No patient exhibited hypersensitivity, fibrinolysis, or coagulopathy following the use of this glue. In 16 patients followed for 9 to 12 months postoperatively, no hepatitis has occurred. The highly concentrated fibrinogen in cryoprecipitate is activated by thrombin to form fibrin and bring about rapid hemostasis. Cryoprecipitate-topical thrombin glue is a readily available, reliable, and inexpensive topical hemostatic agent in the patient undergoing a cardiac operation.

The fate of arm veins used for aorta-coronary bypass grafts.

Arm veins have been a common second choice conduit for those patients having insufficient saphenous veins for coronary bypass operations. To define the patency and durability of arm vein grafts, we reviewed our patients with one or more arm vein grafts used for coronary revascularization between 1974 and 1982. A total of 59 patients required at least one arm vein graft and 51 are presently alive. Postoperative arteriograms were obtained in 28 patients. Of 56 arm vein grafts used, 32 (57%) were patent and 24 (43%) had failed at 2 years. Seven of the patent grafts had a localized area of stenosis. Sixteen internal mammary artery grafts also had been used in this group of patients, and 15 (93%) were patent. We conclude that arm vein grafts have a high failure rate and are not as dependable as saphenous vein grafts or internal mammary artery grafts.

Surgical procedures after percutaneous transluminal coronary angioplasty.

Since Gruentzig's introduction of percutaneous transluminal coronary angioplasty in 1974, there has been increasing clinical use of this technic. At St. Thomas Hospital in Nashville, 50 patients were selected for coronary angioplasty through December 1981. Twenty of the 50 have ultimately had coronary artery bypass surgery. Excellent dilatation of the selected coronary artery was accomplished in 19 patients. Fair dilatation was achieved six times, and four of these patients have had elective coronary artery bypass surgery. In 18 patients the vessels could not be dilated, and 12 of this group had coronary artery bypass, three on an urgent basis. In the remaining seven patients, the affected coronary stenosis was converted to 100% occlusion during the angioplasty, resulting in four emergency operations and one death. It appears that percutaneous transluminal coronary angioplasty is not as easy to master as had been anticipated, and that the results are just good enough in our hands to justify perseverence.

Urgent operation for acquired ventricular septal defect.

Recent experience suggests that ventricular septal defect (VSD) secondary to myocardial infarction constitutes an indication for urgent operation. Acquired VSD at St. Thomas Hospital, Nashville, was reviewed to substantiate the obsolescence of protracted medical therapy designed to allow a late, technically less demanding, repair. Twenty-two acute VSDs (less than four weeks following onset of murmur) have been treated since 1970. Five patients died during medical therapy. Two patients survived for more than four weeks without operation. One never manifested significant cardiac decompensation. The other was operated on at 33 days, after progressive deterioration. No technical advantage from the delay was apparent, although survival was achieved. Ten of 15 patients (67%) operated on during the first four weeks survived. Fourteen had reached a level of marked instability prior to operation. Of the five deaths, four were technical and were the product of an initial lack of recognition of the necessity for patch replacement of the interventricular septum. The prosthetic patch is now considered essential to minimize suture-line stress in necrotic muscle. Potentially, only one of 15 patients operated on early using current methods would have expired. This experience supports an aggressive surgical approach to any unstable patient with postinfarction VSD. Early repair requires specific techniques. Results of early operation using these techniques are dramatically superior to past efforts designed to delay definitive repair.

Pulmonary embolectomy.

During the past 10 years, 20 patients at St. Thomas Hospital had pulmonary embolectomy; there were 12 survivors. Ten patients had a pulmonary arteriogram prior to operation and, of these, there were 7 survivors. The remaining 10 patients were seen with circulatory collapse and were taken immediately to the operating room without definitive diagnostic studies. Ten patients were undergoing cardiopulmonary resuscitation at the time of the embolectomy and, of these, there were 5 long-term survivors. This review indicates that immediate diagnostic studies, such as lung scan or pulmonary arteriogram, should be undertaken as soon as the diagnosis of pulmonary embolus is entertained. Patients with sudden collapse, in the appropriate clinical setting, should be transported to the operating room as soon as possible. It would also appear that patients who are unresponsive to the usual measures of cardiopulmonary resuscitation are still reasonable candidates for pulmonary embolectomy, and this may represent their only change for survival. Patients in whom massive pulmonary embolus is confirmed by angiography should be considered for early pulmonary embolectomy despite a relatively stable hemodynamic and clinical picture.

Results of surgical management of acute left ventricular aneurysms.

Over an 8-year period, 20 patients underwent operative repair of ventricular aneurysms during the first 8 weeks after acute myocardial infarction. All patients with multivessel coronary occlusive disease underwent concomitant coronary artery bypass grafting. There was one hospital death, for an early mortality rate of 5%, and one late death during follow-up, which now extends over 8 years, for a predicted actuarial 5-year survival rate of 92%. Six of the patients underwent early study and operation because of recurrent ventricular arrhythmias, with resolution of the arrthymia in all. Seventy-five percent of the survivors are not limited by symptoms and 45% are presently working working full time. These results were significantly better than those in patients who underwent operation later after infarction, although the two groups were not strictly comparable. An aggressive approach to surgical therapy in severely symptomatic patients soon after myocardial infarction can afford excellent early and long-term results.

Air embolism and other accidents using pump oxygenators.

A surgery of 349 cardiac surgeons showed that during a six-year period, a pump oxygenator accident serious enough to cause patient injury or death occurred one per 1,000 procedures. A total of 264 deaths occurred as a direct results of an accident. Air embolism and disseminated intravascular coagulation were the two most common problems. Low-level alarm systems were reported to be used by 42% of the respondents and activated clotting times were used by 63%. Rigorous use of alarm systems and heparin monitoring could reduce the incidence of pump-related accidents.

Techniques and results of ventricular aneurysmectomy with emphasis on anteroseptal repair.

We have reviewed an 8 year experience with ventricular aneurysmectomy in 170 patients. Ninety percent had anterior aneurysms and underwent "anteroseptal repair" with exclusion of nonfunctioning septal myocardium. Preoperative left ventriculograms and coronary arteriograms were studied and "scored," and the hospital mortality and long-term survival rates for various subsets of the group were correlated with their radiographic data. A postoperative score for the coronary arteries was developed according to the preoperative anatomy and the vessels bypassed. Both the ventriculogram score and the postoperative coronary score had significant effects on both hospital mortality and long-term survival rates. The severity of preoperative coronary disease had minimal predictive value. Recent myocardial infarction did not preclude a good result. The value of an aggressive surgical approach to patients with ventricular aneurysm was confirmed even for certain subsets with indicators suggestive of poor prognosis. Anteroseptal repair appears to give optimal results for the typical "anterior" aneurysm. All suitable coronary arteries should be bypassed. Attention to the details of preoperative anatomy and function allows the most accurate prediction of prognosis and dictates the optimal therapeutic approach.

The cost of coronary bypass procedures.

We reviewed the financial records of 200 succesive patients who had coronary artery bypass surgery in the first three months of 1976. The average hospital bill was $7,690 and the average length of stay was 18 days. The highest bill was $28,329 (79 days) and the lowest was $6,126 (11 days). The average total physician charge to the patient was $3,240. The total average hospital and physician cost was $10,930.