Surgical management of radiation-induced heart disease.

BACKGROUND: With the increasing population of patients with prior mediastinal irradiation, cardiac surgeons will encounter patients with radiation-induced damage to the heart and the great vessels. Awareness of the pathology and the surgical management is essential to provide optimal care for these patients. METHODS: Eight patients with radiation-induced heart disease were encountered in the last 10 years. After a brief clinical presentation, the surgical management of radiation-induced heart disease is reviewed. RESULTS: Radiation can affect all the structures in the heart, including the coronary arteries, the valves, and the conduction system. The pericardium is the most commonly involved, and the conduction system is the least involved. Pericardiectomy is quite effective in patients with symptomatic pericardial effusion or constriction. The coronary lesions are located predominantly in the ostial or proximal regions of the epicardial vessels. Percutaneous transluminal coronary angioplasty alone appears to have a high rate of restenosis. Surgical revascularization has good long-term results, and the internal mammary artery should be used if it is satisfactory. The aortic and mitral valves are more commonly involved than the tricuspid and pulmonary valves. Myocardial dysfunction predominantly affects the right ventricle and requires particular attention during cardiopulmonary bypass and in the postoperative period. Restoration of sinus rhythm is essential in view of stiffness of the ventricles. Flexibility in the surgical approach with selective use of thoracotomy will facilitate the surgical procedure in certain patients. CONCLUSIONS: Surgeons should be well versed in all the manifestations and the management of radiation-induced heart disease.

Saccular outpouchings of an ascending aortic aneurysm: transesophageal echocardiographic appearance.

The differential diagnosis of cavities in the ascending aorta includes pseudoaneurysms, intimal flaps, and abscesses. We describe the transesophageal echocardiographic and pathologic appearance of a fusiform ascending aortic aneurysm that contained atypical outpouchings that were initially confused with an intimal flap. Awareness of this unreported abnormality and its echocardiographic features will avoid the misdiagnosis of more serious aortic pathology such as acute aortic dissection or infective endocarditis.

Selectivity in aortic root reconstruction.

Anatomical variations in aortic root pathology, including combinations of dissection, aneurysmal dilatation, annuloaortic ectasia, and valve disease, defy standardized repair and mandate application of various surgical reconstructions. To examine these techniques, and their influence on morbidity and mortality, we reviewed 53 consecutive patients undergoing aortic root procedures. Thirty-two patients underwent total root reconstruction. Of these, 21 underwent Bentall procedures, 9 had a modification thereof, and 2 underwent a Cabrol reconstruction. Less extensive pathology was corrected in 21 patients with a partial root reconstruction. These included aortic valve replacement (AVR) and a separate tube graft in 14 patients, AVR and primary aortic repair +/- wrapping in 4 individuals, and AVR and patch aortic root enlargement in 3 patients. Mean age was 53.2 years (range 20 to 79). Nearly 20% had undergone previous cardiac surgery and 7.5% were emergencies. Early mortality was 4%. Complications included dysrhythmias (48%), myocardial infarction (4%), stroke (4%), pneumonia (14%), and pancreatitis (2%). There were no reoperations for bleeding. Three late complications, one pseudoaneurysm and two perivalvular leaks, were successfully repaired. Late deaths (13.7%) were caused by congestive heart failure (3), myocardial infarction (MI) (1), cancer (1), stroke (1), and accidental fall (1). Kaplan-Meier analysis reveals 1-, 5-, and 10-year survivals of 98%, 81%, and 66%. Survival and mortality data did not differ between groups, and except for the incidence of atrial dysrhythmias, complication rates also were not significantly different. This series illustrates the need for and the successful application of a selective approach to aortic root reconstruction.

Automatic implantable cardioverter defibrillator: surgical approaches for implantation.

Surgical approaches for implantation of the automatic cardioverter defibrillator are sternotomy, left thoracotomy, subxiphoid, and subcostal. Although any one of these may be combined with insertion of one or more of the electrodes transvenously, surgical entry into the chest is required for every noninvestigational defibrillator implantation operation. The approaches differ in exposure provided for selecting electrode sites and for handling untoward events, in amount and location of tissue that must be divided or dissected, and in average time required. The operation is an electrical one. Its purpose is to obtain reliable rhythm sensing so that defibrillation or cardioversion shocks will occur only when necessary, and to obtain low enough defibrillation thresholds for shocks of 30 joules or less to have a 10-joule defibrillation safety margin. Many of the patients have had previous cardiac operations. They usually have low or very low ejection fractions. Intraoperative electrophysiological testing with often multiple defibrillation episodes is required. The choice of approach varies with the state of the patient, the institutional experience, and the surgeon. This article describes technique, and the advantages and disadvantages of the four approaches as used by four surgeons in four different institutions.

Inferior vena cava interruption with the Hunter-Sessions balloon: eighteen years' experience in 191 cases.

Over a period of 18 years, 191 consecutive patients had interruption of the inferior vena cava with the Hunter-Sessions balloon for complications of deep venous thrombosis and pulmonary embolism. Causes of deep venous thrombosis and pulmonary embolism included the postoperative state (33%), cancer (32%), and stroke (11%). There were 93 females and 98 males; ages ranged from 17 to 90 years (average, 57 years). Indications for placement of the Hunter-Sessions balloon were as follows: contraindication to anticoagulants (33%), anticoagulant complications (24%), pulmonary embolism despite anticoagulants (45%), and others including inferior vena cava thrombus (12%). Sixty-eight percent had clinical phlebitis and 36% had positive venography results. Pulmonary embolism had occurred in 165 patients (86%). It was diagnosed by ventilation-perfusion scanning (75%), angiography (23%), or on clinical grounds (2%) in patients with confirmed deep venous thrombosis. At the time of the procedure 52% were in significant cardiopulmonary distress, and 10% were intubated and on respirators. Transjugular placement was done in 188 patients, and transfemoral placement was performed in three. All All tolerated inferior vena cava interruption. Thirty patients (15%) died while in the hospital an average of 21 days after balloon placement, which was unrelated to the deaths. Follow-up was 45 months. Ninety-four patients are dead, 95 are alive, and the status of two patients is unknown. Twenty-nine of 64 patients (45%) who died after they left the hospital died of cancer. At last follow-up, 75% of patients had legs free of edema and 25% had need for elastic stockings. No malfunction or migration has occurred with the device. No patient had a pulmonary embolism while in the hospital after insertion of the Hunter-Sessions balloon, and no patient died of pulmonary embolism. Late minor pulmonary embolism occurred in three patients.

Mitral valve dysfunction following papillary muscle cryoablation.

Cryoablation is recognized as a useful modality for diagnostic mapping, as well as for permanent obliteration of arrhythmogenic foci. This technique has been used to eradicate irritable foci at the base of papillary muscles. We report a case of mitral valve dysfunction requiring valve replacement following cryoablation of the posterior papillary muscle. Based on this experience, we caution against extensive cryoablation of papillary muscle tissue because of the possibility of disrupting mitral valve function.

Review of Ehlers-Danlos syndrome. Successful repair of rupture and dissection of abdominal aorta.

Successful surgical treatment of spontaneous rupture and dissection of the abdominal aorta in Ehlers-Danlos syndrome has not been previously reported. A 16-year-old male sustained spontaneous rupture and dissection of the abdominal aorta. Successful surgical treatment included placement of an abdominal aortic bifurcation graft. Genetical, biochemical and clinical differences of seven types of the syndrome are outlined. A brief guideline for treatment and prevention of vascular complications is discussed.

The automatic implantable cardioverter-defibrillator. Clinical experience, complications, and follow-up in 25 patients.

Twenty-five patients with recurrent ventricular tachyarrhythmias underwent implantation of an automatic implantable cardioverter-defibrillator. The mean length of follow-up was 11.9 +/- 10.8 months. Before the implantation, the patients had survived one or more cardiac arrests (mean, 1.7; range, 1 to 4) and episodes of syncope (mean, 2.2; range, 2 to 3) and had received 6.0 +/- 1.0 antiarrhythmic drug trials. The in-hospital complications included death (two patients), reoperation (one patient), intraoperative myocardial infarction (one patient), sensing-failure (one patient), infection (five patients), and pocket seroma (two patients). The posthospital complications included device failure (four patients), device deactivation (one patient), and inappropriate discharge (two patients). The device discharged appropriately in seven patients due to sustained ventricular tachycardia. During electrophysiologic measurements, the energy requirement for successful cardioversion-defibrillation was related to the type of ventricular arrhythmia induced (monomorphic or pleomorphic ventricular tachycardia or fibrillation). Ventricular tachycardia acceleration occurred in ten patients (40%). No significant changes were found in the size of the electrograms or in the cardioversion threshold during early and late follow-up measurements. Life table analysis showed a 12-month survival rate of 86% and an arrhythmic death survival rate of 100%. We confirm the improved rate of survival in this high-risk group of patients, despite significant complications.

Mycotic right coronary artery aneurysm: CT and MR diagnosis.

A clostridial mycotic aneurysm of the right coronary artery was diagnosed by the use of multiple imaging modalities including gated magnetic resonance imaging. Percutaneous drainage was performed as a palliative measure in hope of avoiding repeat sternotomy.

Thromboembolism and cancer: treatment with the Hunter balloon.

Between 1970 and 1982, 126 inferior vena cava (IVC) balloon occlusions were performed for complications of venous thromboembolism (VTE). Forty, or 32%, were in patients with cancer. There were 20 men and 20 women. The average age was 60.8 +/- 2 years. Cancers of the brain, lung, and breast, along with diffuse metastatic disease with unknown primary disease, were equally common and represented 50% of our cases. Indications for IVC occlusion included pulmonary embolus despite anticoagulation (AC); 50% VTE and contraindication to AC, 38%; and complications of AC, 12%. Three patients died from ongoing complications of previous AC. Eight additional patients died of cancer, for a hospital mortality rate of 28%. Twenty-nine patients were discharged an average of 28.4 +/- 4.3 days after IVC balloon occlusion. Twenty of these patients subsequently died of cancer an average of 13 +/- 4.7 months after hospital discharge. Eight patients remain alive, four for more than 4 years. Pulmonary emboli did not occur after balloon occlusion, and there were no balloon complications. Only 4 of 29 discharged patients had mild leg edema. Hunter balloon occlusion of the IVC represents a safe and effective method for managing complications of VTE in patients with cancer. Early hospital discharge is possible, treatment is permanent, and future chemotherapy is not compromised by the need for long-term anticoagulation.

Neurological complications of coronary revascularization.

In a series of 3,206 consecutive coronary artery bypass procedures performed between 1976 and 1981, 89 patients died (2.8% mortality) and 32 patients (1%) suffered major neurological syndromes. Among the latter patients, four distinct groups were identified. Group 1 consisted of 10 patients who remained unresponsive after operation. In Group 2 were 10 patients who awakened after operation but had clinical evidence of focal cerebral infarction. Group 3 included 6 patients who were initially intact neurologically but in whom neurological deficits later developed. In Group 4 were 6 patients who had severe mental aberration but no focal neurological deficits. The incidence of coma or focal deficit occurring without a lucid interval (Groups 1 and 2) was 0.62%, and these patients had a 30% mortality. Causative factors were suspected in 70% of the patients in Groups 1 and 2, and included atheromatous embolism, perioperative hypotension, carotid artery occlusive disease and air embolism. The outcome was poor for unresponsive patients, with 70% dying or remaining comatose, but nearly all of the patients with focal deficits or severe mental aberration demonstrated notable improvement.

Reflections in a normal eye: the effect of aortic stenosis on oculopneumoplethysmography.

The association of aortic stenosis and syncope is well recognized. Oculopneumoplethysmography (OPG) can provide an accurate index of carotid stenosis and indirectly measure cerebral perfusion. The possibility that OPG would be influenced by aortic valve disease was assessed in patients prior to valve replacement. 31 patients were studied. 19 patients had aortic stenosis (AS), 3 had aortic insufficiency (AI), and 10 had mixed lesions. OPG was positive in 15 patients (48%). Considering all forms of aortic valve disease, the likelihood that a positive OPG was indicative of AS with a gradient of greater than 60 mmHg was significant (P = .002). Of 18 patients with AS alone, no patient with a valve gradient greater than 60 mmHg had a negative OPG (P = .0001). OPG became normal in 11 of 12 patients restudied postoperatively. Critical aortic stenosis results in uneven distribution of blood flow into the brachiocephalic vessels. OPG accurately identifies this effect which becomes evident at aortic valve gradients greater than 60 mmHg.

Diaphragmatic left ventricular aneurysm. Clinical features, surgical treatment, and long-term follow-up in 22 patients.

Although the formation of a left ventricular aneurysm (LVA) is a common and well-recognized complication of myocardial infarction (MI), diaphragmatic LVA is a rare clinical entity. Of 354 consecutive patients who underwent LVA resection, we describe the clinical features and surgical results of 22 patients (6%) with diaphragmatic LVA. All patients had a history of MI. The principal clinical indication for surgery was heart failure in nine patients, angina pectoris in ten patients, and recurrent ventricular tachycardia unresponsive to medical therapy in three patients. A ventricular septal defect was present in two patients, and moderate to severe mitral regurgitation was present in four patients. Three of the four surgical deaths (operative mortality, 18%) occurred in patients with mitral regurgitation or with ventricular septal defect. Eleven patients are alive at a mean follow-up of 40 months. Six of them are asymptomatic and two have angina at a higher level of physical activity than before surgery. Notable differences exist in the clinical presentation and surgical findings between patients with diaphragmatic and anterior LVA.

Acute ascending aortic dissection: surgical management.

The success of total aortic root replacement in conditions such as annuloaortic ectasia and complicated redo surgery has stimulated its use in acute dissection of the ascending aorta. We believe this radical approach is, in most cases, unwarranted, considering the excellent results with valve conservation. From 1970-1978, 20 consecutive patients with acute anterior aortic dissection and aortic insufficiency were operated at Rush-Presbyterian-St. Luke's Medical Center. Only one patient (5%) required reoperation for hemorrhage. The three operative deaths (15%) were associated with right coronary artery disruption, aortic-right atrial fistula and preoperative intrapericardial false lumen rupture. In eight patients, valve resuspension was combined with primary aortic repair and nine with ascending graft interposition, but aortic valve replacement was required in three because of annuloaortic ectasia or tissue friability. One patient treated by primary repair in 1971 underwent successful reoperation for redissection 7 years later (1.4% per patient-year risk of late reoperation), but the remaining 16 patients, followed 2-10 years, remain free of aortic insufficiency or recurrent aneurysm. This experience supports the use of valve reconstruction rather than replacement in most cases of acute anterior dissection of the aorta.

Leg wound complications associated with coronary revascularization.

One percent of 2,545 patients undergoing coronary revascularization with the saphenous vein over a 5 year period sustained leg wound complications which necessitated extra care. Fourteen complications were minor and required only drainage, a new antibiotic, and dressing changes. Thirteen major wound complications required wide debridement and, of these, five could be closed only with skin grafts. Eight wounds were infected, two with Staphylococcus aureus and six with mixed gram-negative flora. Ninety-three percent of these wounds were in the thigh. Average weight of patients with leg wound complications was 73.5 +/- 3.5 kg and not different from that of a randomly selected control group (73.8 +/-1.2 kg). However, 40% of the patients were women, a much higher incidence than control (p less than 0.005). Hospital stay increased significantly from 12.1 +/- 0.5 days for the control group to 24 +/- 2.6 days for the group with wound complications (p less than 0.005). Average hospital stay was 33.6 +/- 3.8 days (p less than 0.001) in those patients with major wound complications (estimated hospital cost $9,900). Leg wound complications of saphenous vein harvest are infrequent but serious. Efforts to prevent this complication should include minimal dissection, careful hemostasis, and closure in layers. Development of skin slough, infection, and necrosis necessitating débridement and drainage is a major and expensive complication. Wide excision and direct closure are necessary to minimize hospital stay and reduce the requirement for skin grafting.

Sternal wound complications. Management and results.

Of 4,124 patients undergoing median sternotomy for cardiac operations, 1.8% had sternal wound complications. These included wound drainage, skin separation, unstable sternum, and sternal dehiscence with or without infection. Septicemia and mediastinal abscess were found in all 19 patients who died. Incision and drainage of skin and subcutaneous tissue with frequent changes of dressing or irrigation (Method A) is recommended for those patients with (I) serosanguineous drainage only or (2) a stable sternum and superficial infection without systemic reaction. Surgical débridement of the sternum and mediastinum with reclosure followed by mediastinal irrigation via drainage tubes with 0.5% povidone-iodine solution (Method B) is recommended for patients with (1) a draining, unstable sternum, (2) infection involving the retrosternal space, or (3) infection causing a systemic reaction unresponsive to Method A. None of the eight patients in the latter group with more serious infections died when managed by Method B, and only one had recurrent infection. In contrast, of 28 patients of the latter group not treated with Method B, 11 died of infection-related causes and 13 returned with recurrent infection.

Simultaneous aortic and renal artery reconstruction.

From 1970 to 1978, 39 patients underwent simultaneous aortic and renal artery reconstruction. Of these, 37 had severe single or bilateral renal lesions in combination with an aortic aneurysm, or symptomatic or asymptomatic aortoiliac disease. Two patients had renal arteries that originated from an abdominal aortic aneurysm. Thirty-two patients were hypertensive, one had chronic renal failure, and three others had asymptomatic renal lesions that were bypassed prophylactically. Operations performed included aortic replacement plus: single renal graft; bilateral renal grafts; renal graft plus contralateral nephrectomy; and renal graft plus mesenteric revascularization. All early postoperative deaths (four) occurred in patients with aneurysmal disease. Twenty-nine patients were available for long-term evaluation. In patients who were hypertensive preoperatively, 64.0% experienced long-term cure or improvement. Cardiac and cerebral disease, lower extremity claudication, and the need for subsequent cardiovascular surgery occurred with substantial frequency during the follow-up period.

Requirements for a method of transvenous inferior vena cava interruption.

Six requirements were defined that would characterize a safe and effective technique of transvenous inferior vena cava (IVC) interruption: (1) the instrument should be placed transjugularly under local anesthesia; (2) the instrument should have "built-in" capability for venography; (3) the technique should produce complete occlusion of the IVC; (4) the occluder must adapt to any variable in IVC diameter; (5) the intracaval device must have no sharp edges, pins, or points; and (6) the technique must permit simultaneous heparin therapy. These specifications were met by a catheter-delivered detachable balloon that could be inflated to any needed diameter. This technique was used in 96 patients, with a follow-up period to ten years. Time and experience confirm the validity of the six requirements for a safe and effective technique.