Morbidity and mortality of intra-aortic balloon pumps placed through the aortic arch.

Twenty-four patients required an intra-aortic balloon pump placed through the aortic arch during cardiac operations from 1985 to 1993. The operative procedures of the 24 patients requiring arch balloon pumps included aortocoronary bypass (14), redo aortocoronary bypass (3), valve replacement (3), aortocoronary bypass with concomitant ventricular septal defect repair (1), heart transplantation (2), and aortic to right ventricle fistula repair (1). Mortality was 54%. Morbidity included cerebral vascular accident (17%), acute renal failure (29%), left ventricular thrombus (4%), sternal wound infection (4%), and mediastinal exploration secondary to bleeding from the balloon pump site (4%). This review suggests that (1) mortality for patients requiring arch balloon is significant, (2) complications of cerebral vascular accident and renal failure may be increased, and (3) severe peripheral vascular disease is associated with arch balloon placement and subsequent increased morbidity and mortality.

Radiographic pulmonary abnormalities after different types of cardiac surgery.

One aim of this study was to determine the incidence of new radiographic pulmonary abnormalities during hospitalization after cardiac surgery. Another aim was to determine if such abnormalities are more common among patients who had left internal mammary artery (LIMA) grafting. The predictive value of radiographic abnormalities for clinically important pulmonary morbidity was also determined. The anteroposterior chest radiographs of 152 patients obtained by portable equipment were evaluated to determine the incidence of new postoperative radiographic pulmonary abnormalities such as atelectasis, consolidation, infiltrate, and pleural effusion. Clinically important pulmonary morbidity was defined as a delay in tracheal extubation or discharge from the hospital because of a pulmonary reason. Among the 89 patients who had LIMA grafting and left pleurotomy, there was an 88% incidence of left-sided pulmonary abnormalities; a 73% incidence of left-sided atelectasis; and a 55% incidence of left-sided effusion. Among the 63 patients who had saphenous vein grafting only and/or valvular surgery, the respective incidences were 68%, 54%, and 35%, which were lower (P less than or equal to 0.05) than those in the patients who had LIMA grafting. There was no significant difference in abnormalities between the saphenous vein grafting and the valvular surgery groups. The 35% incidence of left-sided pleural effusion when LIMA grafting and pleurotomy were not performed was unexpectedly high. There was no association between radiographic abnormalities and age, the duration of cardiopulmonary bypass, and the duration of aortic occlusion, indicating that cardiopulmonary bypass was not a primary etiology of these radiographic abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Electrocardiographic J waves after resuscitation from cardiac arrest.

A patient was monitored prior to, during, and after cardiac arrest with a Holter monitor and an electrocardiograph. The arrest occurred without any premonitory signs on the ECG. At the onset of the arrest, torsades de pointes ventricular tachycardia occurred, which quickly degenerated into ventricular fibrillation. After a successful second defibrillation, the patient developed Osborn waves, which subsided within a few minutes.

High-risk heart surgery in the heart transplant candidate.

Because of the limited supply of donor hearts, transplant physicians are searching for alternative treatments for patients referred for orthotopic heart transplantation. A group of 20 patients (7% of patients accepted for heart transplantation at Loyola University Medical Center) were nonrandomly sent for conventional heart surgery. Of 20 patients, 17 survived their hospitalization, and 11 of the original 20 have avoided heart transplantation or having their names added to the transplant list. This group represents a high-risk subset of patients. Patients with poor ventricular function and ventricular arrhythmias or with poor ventricular function who underwent first-time revascularization were well served by more conventional heart surgery (all 10 patients survived surgery). Patients with poor ventricular function who required redo bypass operation had a poor result (three of six died), and such patients should be considered carefully for initial heart transplantation.

Catecholamine sensitive right ventricular outflow tract tachycardia: intraoperative mapping and ablation of a free-wall focus.

A patient with catecholamine-sensitive right ventricular outflow tract tachycardia refractory to pharmacological therapy underwent intraoperative mapping and cryoablation. Epicardial and endocardial mapping demonstrated earliest ventricular activation in the free-wall of the outflow tract, and cryoablation of the area resulted in surgical cure. No histologic abnormalities at the site of tachycardia origin were detected. Catecholamine sensitivity does not appear to result from a diffuse myocardial process, and permanent ablation of the tachycardia in this group of patients with a regional procedure is feasible.

Median sternotomy for implantable cardioverter/defibrillator.

The automatic implantable cardioverter/defibrillator is an accepted mode of therapy for medically refractory sustained ventricular tachycardia or fibrillation. At the Loyola University Medical Center, Maywood, Ill, 39 implantations were performed in a 14-month period. The method of implantation was the median sternotomy. Our population included 9 patients in whom sternotomies had to be redone and 17 patients with concomitant revascularization. Two patients died due to pump failure, and one major complication (infection) occurred that was directly related to the automatic implantable cardioverter/defibrillator. The median sternotomy, because of good results, continues to be our method of choice for insertion of the automatic implantable cardioverter/defibrillator.

Cardiac surgery for chronic renal dialysis patients.

Twenty-two open-heart operations have been performed on 21 patients receiving chronic renal dialysis. These cases include 16 aortocoronary bypasses and six valve replacements. The average time on dialysis prior to surgery was 26 months; 18 of 21 patients were in NYHA grade 3 or 4. Twenty-seven postoperative complications occurred, with six requiring further surgery and 21 treated nonsurgically. Two perioperative deaths occurred, both due to sepsis. Long-term follow-up was achieved on all hospital survivors. Ten patients remain alive with a mean follow-up of 21 months. At a mean of 16.5 months after surgery, nine deaths occurred, with only two due to known cardiac problems. In summary, indicated cardiac surgery can be performed on chronic renal dialysis patients with a reasonable morbidity and mortality; however, the long-term survival of our patients has not been assured by a successful cardiac operation.

Coronary revascularization and implantation of the automatic cardioverter/defibrillator: reliability of immediate intraoperative testing.

Concomitant coronary revascularization and implantation of the automatic cardioverter/defibrillator is an increasingly common procedure. To determine whether cardioversion/defibrillation thresholds measured after weaning patients from cardiopulmonary bypass are sufficient to justify immediate implantation of the pulse generator, we prospectively compared postpump values to those obtained 1 week later in five patients. R-wave amplitudes during both sinus rhythm and ventricular tachycardia, lead impedance, defibrillation thresholds and cardioversion thresholds remained stable or improved from the postpump to the 1 week values. Five other patients had the generator implanted at the time of revascularization. Immediate postbypass cardioversion thresholds (mean 10 +/- 8 joules) in these ten patients did not significantly differ from those of 20 nonpump implantations (VT mean 7 +/- joules; VF 15 +/- 4 joules and defibrillation thresholds mean 17 +/- 6 joules). These findings suggest that the residual effects of cardioplegia, core-cooling and operative ischemia have no significant effects on intraoperative testing of implanted defibrillators. This clinical experience supports the practice of immediate implantation of the pulse generator at the time of revascularization.

Perioperative dissection of the ascending aorta: types of repair.

Iatrogenic aortic injury occurring during either coronary bypass grafting or valve replacement is a well-recognized complication of cardiac surgery. We retrospectively reviewed our experience and found 11 cases occurring in a case load of 8,945 hearts (incidence of 0.12%). All 11 cases were repaired, with 10 patients surviving. The type of repair used usually was determined by when the diagnosis was made. When an intraoperative diagnosis was made, a local repair was done in four of six cases. If a postoperative diagnosis was made, then all five patients needed the ascending aorta replaced. With early diagnosis and rapid repair, good surgical results can be achieved.

Aortic valve replacement in patients 75 years old and older.

A consecutive group of 100 patients in the eighth decade of life who had aortic valve replacement (AVR) from 1975 through 1986 were retrospectively studied. Eighty-five of them were in New York Heart Association (NYHA) Functional Class III or IV. Isolated AVR was performed in 44 patients and AVR with concomitant procedures, in 56. Perioperative mortality (30 days) was 3%, and perioperative morbidity included 83 complications in 60 patients. Long-term follow-up was available on 93 patients, 71 of whom were alive and 22 of whom were dead. Sixty-eight of the 71 long-term survivors are now in NYHA Class I or II. The low rate of perioperative mortality and the improved quality of life after AVR support the performance of this procedure in this older population.

Intra-arterial digital subtraction angiography as a method to study peripheral vascular disease.

In many patients with peripheral vascular disease, conventional arteriograms are not adequate to make proper preoperative decisions. In the past, these inadequate studies led to surgical exploration of vessels and intraoperative angiography to determine operability. Such efforts prolonged operating time and potentially had adverse effects on amputation levels. Recently, intra-arterial digital subtraction angiography (IDSA) has provided an excellent means to further evaluate these patients preoperatively. We presently have 30 patients in whom IDSA supplemented routine aortography and runoff studies. When standard angiographic studies were considered inadequate, the catheter was positioned appropriately and IDSA was obtained. Inadequate lower extremity distal runoff in 23 patients and no proximal or distal runoff in seven patients prompted the IDSA. The IDSA study yielded further information on all patients, and 26 of 30 patients underwent successful bypass operation. In all 17 patients having femoropopliteal or femorotibial bypass, the IDSA was confirmed by an intraoperative (after bypass) angiogram. Nine patients had inflow procedures, and operative findings corroborated the IDSA. Two patients refused surgery and two patients were not candidates for revascularization. The IDSA study provided an accurate "road map," eliminated unnecessary vessel exploration, saved vital operative time, and prevented compromise of potential amputation levels.