Flash pulmonary edema manifesting for the first time after cardiac surgery: case report.

Flash pulmonary edema secondary to renal artery stenosis is an unrecognized complication following cardiac surgery. We report a case and discuss issues surrounding its diagnosis and management.

Brachial plexus injury as an unusual complication of coronary artery bypass graft surgery.

Brachial plexus injury is an unusual and under-recognised complication of coronary artery bypass grafting especially when internal mammary artery harvesting takes place. It is believed to be due to sternal retraction resulting in compression of the brachial plexus. Although the majority of cases are transient, there are cases where the injury is permanent and may have severe implications as illustrated in the accompanying case history.

Aortic regurgitation in rheumatoid arthritis necessitating aortic valve replacement.

Four cases of patients with aortic incompetence secondary to rheumatoid arthritis are presented. All survived aortic surgery (two having bioprosthetic aortic valve replacement and two a homograft aortic root replacement). A review of the pathophysiology and pathology of this rare cause of aortic regurgitation is presented. A rationale for the choice of aortic valve prosthesis is discussed.

Vasorelaxant properties of isolated human internal mammary arteries and saphenous veins: comparative effects of milrinone and sodium nitroprusside.

Internal mammary arteries (IMA) and saphenous veins (SV) are vessels currently used in human coronary artery bypass surgery. In addition to late complications, the vessels may develop spasm perioperatively. We studied isolated IMA and SV from patients undergoing coronary artery bypass graft to reproduce in vitro the phenomenon of vasospasm. Vascular rings were constricted with phenylephrine in a classic organ bath. The effects of two vasodilator agents, milrinone and sodium nitroprusside (SNP), on phenylephrine precontracted vessels and as a pretreatment to reverse or prevent the contraction, respectively, were studied. When added to a precontracted vessel, milrinone had the same vasorelaxant effect as SNP in artery rings (EC50: 7.4 x 10(-7) +/- 0.8 x 10(-7) vs. 5.9 x 10(-7) +/- 0.8 x 10(-7) M, milrinone vs. SNP). In veins, milrinone was less effective in relaxing the rings than SNP (EC50: 15 x 10(-7) +/- 3 x 10(-7) vs. 1.5 x 10(-7) +/- 0.1 x 10(-7) M, milrinone vs. SNP, p < 0.05). If milrinone or SNP was added as a pretreatment, using the EC50 values, the inhibitory effect of milrinone on phenylephrine-induced contractions was greater in arteries than in veins (71 +/- 4 vs. 36 +/- 11% inhibition of maximum contraction to phenylephrine, artery vs. vein, p < 0.05). In arteries, milrinone caused a greater inhibitory effect than SNP (71 +/- 4 vs. 52 +/- 9% inhibition, milrinone vs. SNP, p < 0.05), but similar inhibition in veins (36 +/- 11 vs. 42 +/- 16%, milrinone vs. SNP).(ABSTRACT TRUNCATED AT 250 WORDS)

Leaking false aneurysm of right coronary saphenous vein graft; successful treatment by percutaneous coil embolisation.

An unusual complication after aortocoronary bypass grafting (CABG) is described in which a false aneurysm of the saphenous vein graft to the right coronary artery (RCA) developed and caused profuse intermittent bleeding through the sternotomy wound. The aetiology of this condition is uncertain but it could occur whenever a suture line is present especially in the presence of infection. The diagnosis was made non-invasively by a contrast enhanced computed tomogram and was subsequently confirmed by selective coronary bypass angiography. The pseudoaneurysm was successfully obliterated by coil embolisation of the right coronary graft, which stopped the bleeding immediately and was followed by rapid wound healing.

Calcification modelling in artificial heart valves.

This study has examined a range of methods of studying the calcification process in bovine pericardial and polyurethane biomaterials. The calcification methods include static and dynamic, in vitro and in vivo tests. The analytical methods include measurement of depletion rates of calcium and phosphate from in vitro calcifying solutions, analysis of tissue contents of calcium, histological staining of tissue sections for calcium, X-ray elemental analysis, by scanning electron microscopy, of calcium and phosphorus distributions over valve leaflets calcified in vitro under dynamic conditions. Bovine pericardium, in all test settings, calcified to a much greater degree than polyurethane biomaterials. Polyurethane extracts calcified to a greater degree than bulk polyurethanes. The test protocol used allows progress through increasingly demanding calcification tests, with the possibility of eliminating unsuitable materials with tests of limited complexity and expense.

Chemical modification of bovine pericardium and its effect on calcification in the rat subdermal model.

Specific modification of functional groups in collagen has been used to investigate their influence on calcification and thermal stability of bovine pericardium. Pretreatment of pericardium with iron (III) citrate reduced calcification in the rat subcutaneous implant model, as did acyl azide activation of carboxyl and amide groups. Chondroitin sulphate had no significant effect, while cyanamide treatment was mainly effective in combination with iron (III) citrate. Glutaraldehyde pretreatment restricted reaction with other modifying agents, but, as a post-fixation treatment, improved the thermal stability of other agents. Glutaraldehyde post-fixation had no significant relationship to the calcification rate.

Persistent conduction disturbances following coronary artery bypass surgery: cold cardioplegic vs. intermittent ischaemic arrest (32 degrees C).

Two-hundred patients undergoing coronary artery bypass grafting were analysed to assess the incidence of new and persistent conduction disturbances in the postoperative period. Two groups, each of 100 patients, were studied. One group underwent surgery during cold crystalloid cardioplegic arrest with moderate whole-body hypothermia (28 degrees C). The second group was subjected to intermittent ischaemic arrest with mild whole-body hypothermia (32 degrees C). The incidence of postoperative conduction defects was significantly higher in the cardioplegic group.

Fracture of the Duromedics mitral valve housing with leaflet escape.

We report a case of leaflet embolisation consequent upon a hemicircumferential fracture of the pyrolytic valve housing of a 29 mm mitral Duromedics Valve implanted for seven months. The clinical presentation is discussed and the literature on mechanical valve failure compared. Unlike pivoting disc valves where absent valve clicks equate with serious occluder dysfunction, valve sounds may persist with bileaflet valve malfunction due to the unimpeded movement of the normally functioning second leaflet. Whilst intrinsic structural failure is increasingly uncommon constant clinical awareness of its occurrence in a patient with a mechanical valve presenting with unexplained acute heart failure and pulmonary oedema, and prompt surgical intervention offers the best chance of survival. The aetiology of the primary fracture in this case remains unclear.

Operative considerations in active native valve infective endocarditis.

During a 12 year period from 1974 to 1986, 38 patients with native valve infective endocarditis were treated surgically. All patients were in the active phase of infection at the time of surgery. Surgical intervention was performed as an extreme emergency in 21 patients, 10 patients were operated on the next day, and 7 patients underwent elective surgery within 3-4 days. Indications for operation were heart failure alone in 52% of patients, heart failure accompanied by sepsis and emboli in 42% and uncontrolled sepsis in the remaining 6% of patients. The hospital and late mortality was 10.5% and 5.2% respectively. Recurrence of infection and paravalvular regurgitation was only seen in one case. Thus, we believe that the risk of surgical intervention for infective endocarditis can be minimised if operative treatment is carried out early, before advanced haemodynamic and irrevocable valvular deterioration ensues.

Dysrhythmias following coronary artery surgery. A comparison between cold cardioplegic and intermittent ischaemic arrest (32 degrees C) with the effect of right coronary endarterectomy.

Dysrhythmias, particularly of supraventricular origin, are an important cause of morbidity following coronary artery bypass grafting (CABG). This study compared the incidence of dysrhythmias in patients undergoing CABG using either cold crystalloid cardioplegia or intermittent ischaemic arrest (32 C). We conclude that the incidence correlated well with right coronary endarterectomy irrespective of the technique of myocardial preservation employed and to the exclusion of other variables.

A quick and atraumatic method of autologous vein harvesting using the subcutaneous extraluminal dissector.

Subcutaneous harvesting using an extraluminal vein dissector was used to obtain saphenous and cephalic veins for aortocoronary vein bypass grafting (CVBG) in 428 unselected consecutive patients without complications. The operative technique is simple, quick and easy to learn. Advantages of the method include expeditious harvesting, limited tissue dissection and vein handling, with minimal overt and occult blood loss. Symptomatic benefits include a considerable reduction of leg wound infection (3% superficial inflammation), comfort and improved early mobility. Reduction in late morbidity due to saphenous nerve damage (1.6%), prolonged oedema (0.7%), and delayed sinus formation were also noticeable features. Light and Scanning Electron Microscope (SEM) studies of 57 vein samples showed no excessive trauma to the vein wall but more specifically no evidence of distraction injury to the tributaries when compared with the more traditional dissection technique.

Massive idiopathic spontaneous haemothorax. Case report and literature review.

Haemothorax is a well-recognized sequela of chest trauma, ruptured aortic aneurysm, and inadvertent puncture of intrathoracic vessels during cannulation or intercostal chest drain insertions, as well as numerous intrapulmonary, pleural and mediastinal conditions. However, massive idiopathic haemothorax occurring in an otherwise healthy subject is, extremely rare, with only two cases reported so far. We add another case and review the scanty literature for identifiable aetiological and predisposing pathological factors. The pathogenesis is discussed and the management outlined, emphasising the diagnostic and therapeutic value of thoracoscopy.

Homemade pressure limiting vein testing device.

A device that provides a simple but effective means of controlling and accurately monitoring static distending pressures within the vein throughout testing is described.

A modified needle holder for mitral valve surgery.

Maneuvers to improve access during difficult mitral valve surgery such as excessive traction on the mitral annulus, retraction and inversion are attended with increased risk of serious complications. A needle holder has been designed to facilitate the placement of sutures during mitral valve or other intracardiac procedures where access is difficult.