Management of closed space infections associated with endoscopic vein harvest.

Wound complications are uncommon following endoscopic saphenous vein harvest. However, closed space infections within the endoscopic tunnel may occur and are difficult to manage. We describe the management of closed space infection in 3 patients and a method that allows drainage without unroofing the endoscopic tunnel.

Endoscopic and traditional saphenous vein harvest: a histologic comparison.

BACKGROUND: Vein trauma after saphenectomy by endoscopic or longitudinal techniques may influence the progression of medial and intimal hyperplasia and ultimately affect graft patency. This study compared the histologic characteristics of saphenous veins after endoscopic and longitudinal harvest. METHODS: One hundred seventy patients who underwent elective coronary artery bypass grafting had saphenectomy performed endoscopically (n = 88) or by a longitudinal incision (n = 82). Cross-sectional specimens from endoscopically (n = 151) and longitudinally (n = 158) harvested veins were submitted for hematoxylin-eosin, trichrome, and elastin staining. Blinded histologic evaluation involved graded analysis of endothelial, smooth muscle, and elastic lamina continuity in addition to medial and adventitial connective tissue uniformity. RESULTS: Regardless of harvest technique, endothelial, elastic lamina, and smooth muscle continuity as well as medial and adventitial connective tissue uniformity were not significantly different. CONCLUSIONS: Minor histologic alterations occur during saphenectomy, however, endoscopically and longitudinally harvested saphenous veins are histologically similar.

Risk factors for leg wound complications following endoscopic versus traditional saphenous vein harvesting.

BACKGROUND: Risk factors for leg wound complications following traditional saphenectomy have included: obesity, diabetes, female gender, anemia, age, and peripheral vascular disease. Use of an endoscopic saphenectomy technique may modify the risk factor profile associated with a traditional longitudinal incision. METHODS: From September 1996 to May 1999, 276 consecutive patients who underwent elective isolated coronary artery bypass grafting performed by a single surgeon (K.B.A.) had their greater saphenous vein harvested endoscopically. During the period from January 1999 to May 1999, the surgical records of 643 patients who underwent the same operation and had a traditional longitudinal saphenectomy were reviewed for postoperative leg wound complications. Group demographics were similar regarding preoperative risk stratification and traditionally identified wound complication risk factors (diabetes, gender, obesity, preoperative anemia, and peripheral vascular disease). Leg wound complications were defined as: hematoma, dehiscence, cellulitis, necrosis, or abscess requiring dressing changes, antibiotics and/or debridement prior to complete epithelialization. Follow-up was 100% at six weeks. RESULTS: Leg wound complications following endoscopic harvest occurred in 3% (9/276) of patients versus 17% (110/643) of traditional harvest patients (p < 0.0001). No univariate risk factors for wound complications were associated with endoscopic saphenectomy. Univariate predictors of wound complications following traditional saphenectomy included: diabetes (p = 0.001), obesity (p = 0.0005), and female gender (p = 0.005). Multivariable risk factors for leg wound complications following saphenectomy were traditional harvest technique (OR 7.56, CI 3.8-17.2, p < 0.0001), diabetes (OR 2.10, CI 1.4-3.2, p = 0.0006) and obesity (OR 1.82, CI 1.2-2.8, p = 0.007). CONCLUSIONS: Traditional longitudinal saphenectomy is a multivariable risk factor for development of leg wound complications. Endoscopic saphenectomy modifies the risk factor profile for wound complications and should be the standard of care, particularly for obese and/or diabetic patients who require venous conduit during coronary artery bypass grafting.

Cardiac sympathetic denervation after transmyocardial laser revascularization.

BACKGROUND: Transmyocardial laser revascularization (TMR) has been shown to improve refractory angina not amenable to conventional coronary interventions. However, the mechanism of action remains controversial, because improved myocardial perfusion has not been consistently demonstrated. We hypothesized that TMR relieves angina by causing myocardial sympathetic denervation. METHODS AND RESULTS: PET imaging of resting and stress myocardial perfusion with [13N]ammonia (NH3) and of sympathetic innervation with [11C]hydroxyephedrine (HED) was performed before and after TMR in 8 patients with class IV angina ineligible for CABG or PTCA. A mean of 50+/-11 channels were created in the left ventricle (LV) with a holmium:YAG laser. A semiautomated program was used to determine NH3 uptake and HED retention in the LV. Perfusion and innervation defects were defined as the percentage of LV with tracer uptake or retention >2 SD below normal mean values. All patients experienced improvement in their angina by 2.4+/-0.5 angina classes after surgery, P=0.008. Sympathetic innervation defects exceeded resting perfusion defects in all patients before TMR (34.6+/-27.3% for HED versus 9.4+/-10.8% for NH3, P=0.008). TMR did not significantly affect resting or stress myocardial perfusion but increased the extent of sympathetic denervation in 6 of 8 patients by 27.5+/-15.9%, P=0.03. In the remaining 2 patients, both sympathetic denervation and stress perfusion defects decreased after surgery. CONCLUSIONS: TMR causes decreased myocardial HED uptake in most patients without significant change in resting or stress myocardial perfusion, suggesting that the improvement in angina may be at least in part due to sympathetic denervation.

Transmyocardial revascularization utilizing a holmium:YAG laser.

OBJECTIVE: To evaluate the efficacy of transmyocardial revascularization performed on patients with refractory class IV or unstable angina with a holmium:yttrium-aluminum-garnet laser. METHODS: Transmyocardial revascularization with a holmium:yttrium-aluminum-garnet laser was performed in 42 patients with refractory angina who were not candidates for percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. Patients had either Canadian Heart Association class IV angina (n = 23) or unstable angina (n = 19) and were unable to be weaned from intravenous nitroglycerin. Preoperative thallium studies identified the extent and location of reversible ischemia. Operative exposure was via a limited left anterior thoracotomy. An average of 45+/-11 laser channels were created with a mean operative time of 106+/-38 min. RESULTS: Perioperative mortality was 12% (5/42) with no late deaths. Complications included ventricular 7.1% (3/42) and atrial 4.7% (2/42) arrhythmias, reoperation for chest-wall hemorrhage 2% (1/42), and respiratory failure requiring reintubation 2% (1/42). Intra-aortic balloon pump placement was required in 12% (5/42). The mean postoperative length of stay was 5.5+/-4.9 (1-25) days. Mean follow-up on 100% of patients is 5.4+/-3.0 (1-12) months. At 3 (n = 33) and 6 (n = 21) months follow-up the mean angina class was 1.5+/-0.1 (P < 0.002) and 1.1+/-0.1 (P < 0.001), respectively. CONCLUSIONS: Transmyocardial revascularization utilizing a holmium:yttrium-aluminum-garnet laser resulted in a significant reduction in angina class and was beneficial in patients with refractory angina untreatable by conventional methods.

Endoscopic versus traditional saphenous vein harvesting: a prospective, randomized trial.

BACKGROUND: Saphenous vein harvested with a traditional longitudinal technique often results in leg wound complications. An alternative endoscopic harvest technique may decrease these complications. METHODS: One hundred twelve patients scheduled for elective coronary artery bypass grafting were prospectively randomized to have vein harvested using either an endoscopic (group A, n = 54) or traditional technique (group B, n = 58). Groups A and B, respectively, were similar with regard to length of vein harvested (41 +/- 8 cm versus 40 +/- 14 cm), bypasses done (4.1 +/- 1.1 versus 4.2 +/- 1.4), age, preoperative risk stratification, and risks for wound complication (diabetes, sex, obesity, preoperative anemia, hypoalbuminemia, and peripheral vascular disease). RESULTS: Leg wound complications were significantly (p < or = 0.02) reduced in group A (4% [2 of 51] versus 19% [11 of 58]). Univariate analysis identified traditional incision (p < or = 0.02) and diabetes (p < or = 0.05) as wound complication risk factors. Multiple logistic regression analysis identified only the traditional harvest technique as a risk factor for leg wound complications with no significant interaction between harvest technique and any preoperative risk factor (p < or = 0.03). Harvest rate (0.9 +/- 0.4 cm/min versus 1.2 +/- 0.5 cm/min) was slower for group A (p < or = 0.02) and conversion from endoscopic to a traditional harvest occurred in 5.6% (3 of 54) of patients. CONCLUSIONS: In a prospective, randomized trial, saphenous vein harvested endoscopically was associated with fewer wound complications than the traditional longitudinal method.

Routine surveillance endomyocardial biopsy: late rejection after heart transplantation.

BACKGROUND: Transplant programs use routine surveillance endomyocardial biopsies (RSEMB), which are performed at preset intervals to diagnose cardiac rejection. This retrospective study determined the incidence of graft rejection detected by RSEMB. METHODS: The records of 95 patients who underwent heart transplantation between 1987 and 1995 were reviewed. Rejection incidence was recorded for 80 patients who survived at least 30 days, with a mean follow-up of 35 months. RESULTS: One thousand five hundred sixteen total biopsies were performed; 1,170 were RSEMB. Four hundred seventy-five total rejection episodes occurred and 269 (56%) were diagnosed by RSEMB. Two distinct patient groups were identified. The majority (70 patients), had a decline in the incidence of rejection and no rejection episodes were identified by RSEMB after 36 months. In contrast, the high rejection group (10 patients) had a significantly higher ongoing rejection rate (p < or = 0.04 to p < or = 0.001) throughout their postoperative course up to 72 months. CONCLUSIONS: The majority of our transplant patients demonstrate a decrease in rejection with time and do not require RSEMB beyond 30 months. We identified a group of patients who exhibited a higher rate of rejection and need continued RSEMB.

Minimally invasive versus conventional reoperative coronary artery bypass.

BACKGROUND: Conventional reoperative (redo) coronary artery bypass grafting (CABG) is associated with significant morbidity. This retrospective study compared perioperative outcomes of conventional single-vessel redo CABG versus redo CABG done by a minimally invasive technique. METHODS: Group A consisted of 23 consecutive patients from September 1995 to July 1996 who underwent single vessel redo CABG of the left anterior descending artery with the left internal mammary artery using a limited anterior thoracotomy without cardiopulmonary bypass; group B consisted of 12 consecutive patients from November 1984 to July 1994 who underwent the same procedure using a median sternotomy with cardiopulmonary bypass. The two groups were similar with regard to age, sex, preoperative ejection fraction, and risk stratification. RESULTS: Mortality, cerebrovascular accidents, myocardial infarctions, and reoperations for bleeding were not significantly different between the groups. However, the patients in group A had significant reductions in atrial fibrillation, time to extubation, transfusions required, and length of cardiac recovery and hospital stay. With a mean of 12 +/- 6 months of follow-up, 87% of the patients in group A (20 of 23) are alive and asymptomatic. Actuarial survival rates for the patients in group B at 1, 2, and 10 years are 83%, 83%, and 72%, respectively. CONCLUSIONS: Minimally invasive single-vessel redo CABG can be performed safely and may reduce the morbidity associated with conventional single-vessel redo CABG.

Temporary left-sided mechanical cardiac support during acute myocarditis.

Acute myocarditis is usually a self-limiting viral illness. Rarely, however, myocardial depression can be profound leading to circulatory collapse. Mechanical cardiac support in the form of intraaortic balloon pumps or ventricular assist devices have been used in these unusual cases to maintain systemic perfusion until transplantation or left ventricular recovery occurs. We report a young patient with acute myocarditis who required left heart mechanical support and who, however, was successfully weaned despite only minimal myocardial recovery.

New trends in the management of congenital heart disease.

Considerable improvements have been made in the diagnosis and treatment of congenital heart disease during the last decade. Many congenital heart lesions are now treated successfully during the neonatal period that previously were associated with high mortality. Improved echocardiographic imaging, catheterization techniques, and earlier surgical repair are factors that have resulted in greater success in the treatment of congenital cardiac disease. Diagnosis has been improved greatly with advancements in echocardiography and angiography. Better ultrasound technology combined with doppler techniques and transesophageal echocardiography allow more accurate preoperative assessment and therefore more successful surgical repair. Cardiac catheterization techniques have also improved and, when combined with treatment such as balloon angioplasty, have changed the treatment of certain cardiac anomalies such as pulmonary stenosis or coarctation of the aorta. Operative treatment of congenital heart disease has improved the short- and long-term survival of most infants with congenital cardiac anomalies. Improved cardiopulmonary bypass techniques, better suture material, and the ability to perform cardiac transplantation are examples of technology that allows earlier, more complete repair of these complex cardiac defects. Reviewed here are improvements in the treatment of four complex cardiac anomalies that occur in newborns and are associated with high mortality when left untreated. All four anomalies have undergone significant changes in the approach to their treatment with dramatic improvements in survival.

Angioscopic valvulotomy: evaluation of a new miniaturized prototype.

This study compares valvulotomy performed by a new experimental instrument delivered through the angioscope with the standard technique used in the in situ arterial bypass procedure. Eighteen mongrel dogs (approximately 20 kg) were anesthetized and both femoral veins were exposed from the groin to the knee. A 2.5-mm-external-diameter angioscope was passed through the medial saphenous vein to just below the proximal superficial femoral vein valve. Under direct vision, an experimental valvulotome passed through one of the angioscope ports cut the valve leaflets. In the contralateral limb, a Mills valvulotome was inserted in the same fashion and blindly cut the valve. Operative time was recorded and difficulties were noted. Bilateral ascending lower limb venography, animal sacrifice, and removal of the vein segment containing the area of previous valvulotomy for gross and histologic study were performed immediately (n = 3), and at 2 (n = 3), 7 (n = 3), 21 (n = 4), and 42 (n = 5) days after valvulotomy. In each case, both techniques had cut the valve leaflets by visual and histologic evaluation. It took significantly longer to perform the operative procedure with the angioscope (8.0 +/- 3.7 min) than with the Mills valvulotome (0.8 +/- 0.4 min) (P less than or equal to .001, Student's ttest). There was no difference in the patency of the venous system by venographic study but evaluation for a histologically normal venous system was more common with the Mills technique. The angioscopic technique demonstrated 8 of 18 samples to be histologically normal versus 14 of 18 by the Mills technique (P less than or equal to .05, chi-square test). Both techniques are effective in valve leaflet incision. The new angioscope device is more technically demanding (e.g., operative time) and may be more traumatic (e.g., histologic study). However, a gross estimation of luminal damage (venography) does not find the angioscopic method more thrombogenic. The new angioscopically directed device for venous valvulotomy does function effectively. However, adaptation to the in situ bypass technique to replace present angioscopic methods or blind valvulotomy methods requires an appraisal of just what degree of intraluminal trauma is permissible before the risks outweigh the possible benefits.

Anterior pericardial tracheoplasty for congenital tracheal stenosis.

Congenital tracheal stenosis may be a life-threatening anomaly not relieved by airway intubation. Over the past 7 years, anterior pericardial tracheoplasty has been used at our institution for treatment of congenital long-segment tracheal stenosis in infants with impeding airway obstruction. Case histories of eight patients undergoing nine anterior pericardial tracheoplasties have been reviewed to assess this technique. Of these patients, six have required preoperative tracheal intubation before repair to maintain ventilation. The surgical technique of anterior pericardial tracheoplasty includes a median sternotomy approach with partial normothermic cardiopulmonary bypass. An anterior tracheotomy through all hypoplastic rings allows enlargement with autologous pericardium to 1.5 times the predicted normal diameter. After insertion, the pericardium and hypoplastic tracheal cartilages are suspended to surrounding mediastinal structures, which prevents airway collapse. Seven of eight infants have survived without tracheoplasty dehiscence or wound infections. Five were ultimately extubated and are currently free of symptoms from 6 months to 5 years after anterior pericardial tracheoplasty. The other two survivors had residual stenosis as a result of complications of prior tracheostomy. One of these patients has undergone a successful second anterior pericardial tracheoplasty and is currently extubated and well. The other is palliated at 6 months with a tracheostomy awaiting a second anterior pericardial tracheoplasty. Our review of anterior pericardial tracheoplasty has demonstrated the safety, utility, and at least medium-term benefit of this procedure in infants of any age and weight.

Assessing the feasibility of bronchoplastic surgery with magnetic resonance imaging.

Bronchoplastic surgical techniques may allow resectional therapy for non-small cell lung carcinoma in select patients in whom preoperative pulmonary function demonstrates prohibitive risk for pneumonectomy. We report an otherwise poor candidate for pneumonectomy in whom coronal magnetic resonance imaging demonstrated the potential for distal bronchial salvage.

Cor triatriatum: clinical presentation and surgical results in 12 patients.

Twelve patients with cor triatriatum have been seen at our institution since 1979. The clinical presentation, diagnostic evaluation, and surgical results are outlined in this retrospective review. Operation is the treatment of choice for this rare congenital cardiac defect. One patient died 1 day before scheduled operation, and 2 patients died postoperatively, yielding a surgical mortality rate of 17% and an overall mortality rate of 25%. Resection of the obstructing atrial membrane was performed using hypothermic cardiopulmonary bypass in all cases. Left atriotomy was performed in 6 patients, and right atriotomy was performed in 7. The two postoperative deaths occurred in patients who had serious associated cardiac defects. Associated anomalies include atrial septal defect, persistent left superior vena cava, and partial anomalous pulmonary venous return. The postoperative course has been excellent in all 9 surviving patients; all remain asymptomatic. Cor triatriatum is amenable to surgical repair with excellent results when diagnosed early and when not complicated by other severe cardiac anomalies.

The role of pancreaticoduodenectomy in the management of traumatic injuries to the pancreas and duodenum.

Pancreaticoduodenectomy has been decried as a means of managing combined pancreatic and duodenal trauma. In order to test this harsh assessment, we have reviewed our experience with this procedure in this setting. Six young males with a mean injury severity score of 15.4 underwent pancreaticoduodenectomy for trauma. Four patients sustained penetrating trauma and two patients suffered blunt injuries; each was felt by clinical assessment to have pancreatic ductal disruption combined with significant duodenal injury. Four patients underwent pancreaticoduodenectomy primarily, while two patients underwent initial drainage and diverticulization. The four patients undergoing immediate resection had a mean hospital stay of 28 days (18-42 days) and did not require further surgical intervention. All are alive and well six months to nine years later. The two patients with drainage and repair of their injuries had a mean hospital stay of 115 days (84-147 days) and required additional laparotomies for pancreatic leaks, enterocutaneous fistulae, or drainage of abscesses. Pancreaticoduodenectomy was ultimately performed in each case, and both have survived. Pancreaticoduodenectomy continues to have a role in the management of combined pancreatic and duodenal injuries.

The effect of increased intracranial pressure (ICP) on gastric motility.

This study evaluates the effect of increased intracranial pressure (ICP) on gastric motility. Nine male cats (weight, 4.84 +/- 1.16 kg) were anesthetized with ketamine and underwent laparotomy for placement of bipolar (silver-silver chloride) electrodes on the serosal surface of the gastroesophageal junction (GEJ), antrum, and prepyloric areas of the stomach. At 1 week frontoparietal burr holes were performed with placement of an epidural Fogarty catheter. Migrating myoelectric complexes (MMCs) were evaluated at the GEJ, antrum, and prepyloric areas at varying levels of ICP (baseline and 20, 40, and 60 mm Hg) using balloon inflation. MMCs at the GEJ were triphasic with a period of 4 sec (+/- 1 sec) at baseline levels. At ICP levels above baseline, periodicity and waveforms at the GEJ became irregular. Waveforms became multiphasic with 1- to 2-sec periods and variable amplitudes. In the antral and prepyloric areas, duration and amplitude of the triphasic MMCs was unchanged from baseline. At 60 mm Hg ICP periodicity was significantly altered at both 1 and 2 weeks. MMCs returned to baseline levels with balloon deflation. The data indicate that elevated ICP (to 60 mm Hg) results in consistent and reproducible alterations of MMC periodicity, suggesting that such alterations may influence gastric motility.