Manubrium-sparing sternotomy and off-pump coronary artery bypass grafting in patients with tracheal stoma.

The presence of a tracheal stoma in patients with previous total laryngectomy who require cardiac operations is associated with an increased risk of wound complications and tracheal injuries when a full sternotomy is used. The aim of this report is to describe a technique of manubrium-sparing sternotomy, which can be used in patients undergoing coronary artery bypass grafting without cardiopulmonary bypass.

Partial left ventriculectomy to treat end-stage heart disease.

BACKGROUND: It is reasoned that reducing left ventricular diameter (Laplace's law) in patients with dilated cardiomyopathy, will improve ventricular function. METHODS: Partial left ventriculectomy was performed in 120 patients with end-stage dilated cardiomyopathies of varying causes. Most patients were in New York Heart Association functional class IV. The procedure consisted of removal of a wedge of left ventricular muscle from the apex to the base of the heart. Depending on the distance between the two papillary muscles, the mitral valve apparatus was either preserved, repaired, or replaced with a tissue prosthesis. RESULTS: The 30-day mortality was 22% and the 2-year survival was 55%. Although 10% of surviving patients showed no improvement in New York Heart Association functional class, most of the surviving patients were in either class I (57%) or II (33.3%), and the others were in class III and IV. CONCLUSIONS: Partial left ventriculectomy can be used to treat end-stage dilated cardiomyopathy. Further studies and a longer follow-up period are needed to fully assess the effects of this procedure.

Heart and lung grafts harvested en bloc: operative technique, utilization, and results.

Combined heart and lung transplantation has been shown to provide successful therapy for patients with end-stage heart and lung disease. The improved success of lung transplantation has resulted in increasing number of potential recipients and longer waiting times. Maximal utilization of all three thoracic organs is no longer a casual goal but of utmost necessity. We devised a new technique that improves operative visualization, decreases dissection time, and ensures excellent preservation of all three thoracic organs. Bench dissection after extraction of this heart-lung block allows the thoracic and cardiac surgeons to agree on precise dissection of the left atrium and adequate pulmonary venous and atrial cuff. This technique has been used in 48 of our last 50 harvests with excellent results. Utilization of heart and lungs has been 93% and 74%, respectively.

Renal perfusion with the Biomedicus pump during resection of an abdominal aortic aneurysm.

Renal artery perfusion is usually unnecessary during resection of an abdominal aortic aneurysm, because most of these aneurysms are situated below the renal arteries. The authors report the interesting case of a patient with a solitary functioning kidney, who had undergone previous bypass grafting from the right iliac artery to the right renal artery and in whom the kidney was perfused with the Biomedicus pump during the repair of an abdominal aortic aneurysm. This technique may be useful in special situations in which any period of renal ischemia might be hazardous to renal function.

Retrograde continuous warm blood cardioplegia: a new concept in myocardial protection.

This report presents the results in our first clinical series of patients receiving continuous warm blood cardioplegia through the coronary sinus. Warm oxygenated blood cardioplegia has certain theoretical advantages, such as continuously supplying oxygen and substrates to the arrested heart while avoiding the side effects of hypothermia. Retrograde infusion of cardioplegia also offers certain advantages (eg, in valve operations and in patients with severe coronary artery disease) that are complementary to warm blood cardioplegia. Retrograde warm blood cardioplegia was used in 113 consecutive patients (85 men and 28 women with a mean age of 61 years) undergoing various procedures. Three percent of the patients died, 7% needed transient intraaortic balloon pump support, 6% had evidence of perioperative myocardial infarction, and 96% had spontaneous return of rhythm. There were no coronary sinus injuries. This new technique of retrograde continuous warm blood cardioplegia is a simple, safe, and reliable method of myocardial protection that may change the way we currently protect the heart intraoperatively.

Repair of incisional hernia.

Because wound infection is a major cause of incisional hernia, the question posed is whether or not repairs of incisional hernias are at a higher risk for wound infection also. To answer this, we analyzed the incidence of wound infection after repair of incisional hernias during a 30 month period and compared it with the infection rate in all other clean procedures performed during the same period. All repairs of incisional hernias were performed upon patients with completely healed incisions without clinical signs of infection. Patients undergoing concomitant procedures upon the gastrointestinal tract were excluded. During the 30 month period, 995 clean operations were performed. In the 80 repairs of incisional hernias, there were 13 infections proved by culture, yielding an over-all infection rate of 16 per cent. In the remaining 915 clean procedures, there were 14 wound infections (1.5 per cent, p less than 0.0001). Of these 915 clean operations, 241 were repairs of inguinal hernias. Two infections occurred in this subgroup (0.8 per cent, p less than 0.0001, compared with repairs of incisional hernias). In patients undergoing repairs of incisional hernias with previously documented wound infections, 41 per cent had infected repairs. By comparison, only 12 per cent of patients without a prior infection had infections develop in the hernial repair (p less than 0.05). The infection rate for patients not receiving prophylactic antibiotics (21 per cent) was almost twice the rate for those receiving antibiotics (11 per cent), p = 0.07. We concluded that repair of incisional hernias has a significantly higher rate of infection than do other clean general surgical procedures. Herniorrhaphy of a wound that was previously infected is at a higher risk for reinfection, despite complete healing of the skin and absence of clinical signs of infection. Perioperative antibiotic prophylaxis may be indicated, but randomized studies are needed. For reporting and surveillance purposes, repairs of incisional hernias should not be classified as clean surgical procedures.