Esmolol: safety and efficacy in postoperative cardiothoracic patients with supraventricular tachyarrhythmias.

Esmolol, an intravenous, ultrashort-acting beta-blocker, was studied for its ability to safely control supraventricular arrhythmias up to 24 hours in 15 postoperative cardiothoracic surgery patients with atrial fibrillation or flutter and rapid ventricular response. Esmolol obtained an initial therapeutic response in nine (60 percent) patients. Mean heart rate for the 15 patients was reduced from 139 +/- 12 beats/min before therapy to 106 +/- 21 beats/min during esmolol infusion (p less than 0.01). The mean time to a therapeutic response after initiation of therapy, using a multistep titration regimen (500 micrograms/kg/min loading infusions over one minute, prior to incremental titration steps from 50 to 300 micrograms/kg/min over 4 to 14 minutes), was 22 +/- 9 minutes, and therapy was continued for 17 +/- 9 hours in responders. Esmolol significantly lowered blood pressure in the group studied and resulted in mild supine or orthostatic hypotension in ten (67 percent) patients. Side effects, including hypotension (10/15 patients), gastrointestinal disturbances (2/15), and weakness or somnolence (6/15), were transient and were not associated with serious clinical sequelae. We conclude that esmolol is effective for rate control in a majority of postoperative cardiothoracic surgery patients with atrial fibrillation or flutter. Side effects, although mild, occur relatively frequently, limiting prolonged infusions and warranting close surveillance of patients.

Transthoracic intraaortic balloon pump support: experience in 39 patients.

From June, 1982, through July, 1985, 39 (1.5%) of 2,570 patients undergoing open-heart procedures required insertion of a transthoracic intraaortic balloon pump (IABP). In all of these patients, a percutaneous attempt failed or was contraindicated. There were 24 (62%) men and 15 (38%) women. The mean age was 64.9 years. Five patients (13%) sustained complications potentially related to the transthoracic IABP. They included mediastinal infection in 1 patient (2.5%), balloon rupture in 2 patients (5%), and cerebrovascular accidents in 4 patients (10%). The overall survival was 44%. Survival for the group of patients weaned from transthoracic IABP support was 17 (81%) of 21. There were no deaths directly related to the transthoracic IABP. The transthoracic IABP was removed under local anesthesia without sternotomy in 19 (90%) of the patients weaned and with formal sternotomy in the remaining 2 (9%). In a select group of patients requiring intraaortic balloon counterpulsation, the use of the transthoracic IABP is a reasonable second choice for patients in whom other methods of balloon support are not feasible.

Disc embolization of Björk-Shiley mitral prosthesis without strut fracture.

Strut fracture with subsequent embolization of the Björk-Shiley mitral prosthesis is a rare but recognized complication. A case of disc embolization without strut fracture was managed successfully by early surgical intervention. The preoperative chest x-ray film demonstrating apparently intact major and minor struts underscores the importance of a high index of suspicion to make an early diagnosis.

"Tire patch" angioplasty: a new method of arterial repair.

A method of controlling a problematic aortotomy suture line using an onlay patch of polytetrafluoroethylene (Gore-Tex) is described. This method has been used successfully in several instances with good control of bleeding and no complications.

Endotracheal intubation using percutaneous retrograde guidewire insertion followed by antegrade fiberoptic bronchoscopy.

Although endotracheal intubation can usually be performed readily by many medical and paramedical personnel, it may be very difficult in situations such as trauma, hemorrhage, or deformity. We inserted an endotracheal tube over a retrograde guidewire in a patient with a cervical deformity. Published reports of retrograde intubation are reviewed.

Reoperation for stenotic saphenous vein bypass grafts without cardiopulmonary bypass or shunt.

From October 1982 through February 1985, six patients have undergone seven reoperative revascularization procedures for stenosis of coronary artery vein bypass grafts without the use of cardiopulmonary bypass or intraoperative shunt. All patients had prior coronary artery saphenous vein bypasses, ranging from 2 months to 5 years preoperatively. All patients survived reoperation and there was no morbidity. Patients have been followed-up to 26 months. One patient underwent postoperative cardiac catheterization at 1 year, which revealed a patent interposition graft, and one patient had a second operation for restenosis of a vein graft. To decrease the risk of morbidity and mortality in reoperative procedures for saphenous vein graft stenosis, a technique is described that avoids the use of cardiopulmonary bypass or intraoperative shunt. This technique has been used successfully for seven reoperative revascularization procedures and is recommended for selected cases.

Effect of phentolamine in controlling temperature and acidosis associated with cardiopulmonary bypass.

This study assessed the effects of phentolamine on rewarming patterns and metabolic acidosis in 37 patients subjected to hypothermia during cardiopulmonary bypass for the performance of aortocoronary bypass grafting. An additional 16 patients undergoing the same surgery received no phentolamine and served as a control group. In all patients, sodium bicarbonate (44.6 mEq) was administered only when the negative base excess was 3.0 mEq/L or greater. Sixty-eight percent of the patients receiving phentolamine and 56% of the control patients exhibited a uniform rewarming pattern in which the rectal, hand, and foot temperatures increased in parallel. In 32% of the patients receiving phentolamine and in 44% of the control patients, rectal and hand temperatures increased more than foot temperature during rewarming. Analysis of base excess values in the subgroups of patients with similar rewarming patterns indicated that base deficits were significantly decreased in patients receiving phentolamine. Phentolamine administration was also associated with significantly lower blood lactate levels and sodium bicarbonate requirements, as well as improvements in overall appearance and mental status. These data suggest that the routine use of phentolamine in patients undergoing cardiopulmonary bypass may be associated with more uniform body cooling and rewarming and improved tissue perfusion.

Efficacy and safety of intravenous tocainide compared with intravenous lidocaine for acute ventricular arrhythmias immediately after cardiac surgery.

In this double-blind parallel study, 99 patients with acute ventricular tachyarrhythmias after open-heart surgery were given either tocainide (50 patients) or lidocaine (49 patients) intravenously as 2 bolus injections 15 minutes apart, plus a fixed-rate infusion that started at the first bolus. If needed, a third bolus was administered and simultaneously the infusion rate was doubled. The boluses and initial infusion rate for tocainide treatment were, respectively, 250, 250 and 125 mg and 1.04 mg/min, and for lidocaine treatment, 100, 50 and 50 mg and 2.08 mg/min. When efficacy was defined as 80% or greater reduction in single ventricular premature complexes (VPCs) or complete abolition of ventricular couplets or ventricular tachycardia, no difference in efficacy between the 2 treatments was found by bedside electrocardiographic monitoring. By computer analysis of 24-hour taped electrocardiograms and a regression analysis of the proportion of patients responding favorably to treatment, it was estimated that an 80% or greater reduction of single VPCs occurred in 55% of patients during tocainide treatment and in 48% of patients during lidocaine treatment; abolition of couplets occurred in 74% and 68% of patients, respectively; and abolition of ventricular tachycardia in 87% and 73% of patients, respectively. These treatment-related differences were different (p less than 0.004). Adverse reactions occurred in 5 patients (10%) given tocainide (hypotension in 4; junctional rhythm in 1 patient; and nausea-vomiting in 1) and led to discontinuation of treatment in 3 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of Janke-Barron retractor for exposure of the arteries during bypass surgery.

The Janke-Barron heart support was used successfully on 1500 patients who required coronary artery bypass surgery to at least two vessels. The significant advantages it provided were improved exposure and access to all coronary arteries, elimination of damage caused by an assistant holding the heart, provision of a dryer operating field, and allowance for a smaller incision without compromising exposure of the heart.

Control of postcardiotomy bleeding with PEEP.

One hundred consecutive patients undergoing open-heart operation were selected for investigation of the prophylactic and therapeutic use of positive-end-expiratory pressure (PEEP) to control postoperative bleeding. Five cm of PEEP was applied after placement of sternal wires. Patients who bled more than 200 ml per hour were treated with increasing increments of PEEP until hemorrhage terminated or reoperation was required. After 8 hours, the total blood loss per patient was 281 ml for the PEEP group versus 340 ml for the controls (p greater than 0.05). Other variables showed no significant differences. Fifteen patients bled an average of 406 ml (range, 242 to 991 ml) in the first hour in the intensive care unit; they formed the PEEP treatment group. In all patients bleeding decreased to less than 60 ml per hour within 3 hours. No complications of PEEP occurred, and no patient required reoperation to control hemorrhage.

Surgical therapy of variant angina associated with nonobstructive coronary disease.

Patients with variant angina refractory to medical therapy pose a difficult management problem. We report two patients with variant angina who had focal spasm in coronary arteries with fixed obstructions of less than 20% of the luminal diameter. Ischemic episodes were accompanied by malignant ventricular arrhythmias and third degree atrioventricular block. Symptoms were refractory to intensive medical management with nitrates and calcium blocking agents in one patient and with nitrates in the other who was treated before calcium blockers were available. Surgery was done; a bypass graft was placed distal to the area of focal spasm and the native artery was ligated proximally. Both patients are asymptomatic 24 and 66 months after surgery and neither takes anginal medication regularly. The surgical procedure outlined should be considered only if therapy to control life threatening ischemic symptoms with nitrates and calcium blocking agents fails.

Cardiovascular effects of protamine sulfate in man.

The effect of protamine sulfate on several cardiovascular and biochemical variables was studied in man under clinical conditions. This study was performed to quantitate these effects in 15 adult patients who had undergone cardiopulmonary bypass for coronary artery bypass grafting. Protamine was administered in typical clinical doses (3 mg/kg) at typical clinical rates (total dose infused over 5 minutes). This infusion rate is greatly in excess of the 50 mg/10 min suggested in the protamine package insert. No statistically significant changes in mean arterial blood pressure, cardiac output, central venous pressure, total or ionized calcium, PaO2, PaCO2, pH, Na+, or K+ were found during or after administration of protamine sulfate. Hypotension was observed after administration of protamine to one patient, but no etiologic mechanism was apparent. Previous reports suggest cardiovascular depression by protamine in the dog, a species highly susceptible to these effects. Data obtained in man in this study do not corroborate the canine studies.

The intraaortic baloon pump: an analysis of five years' experience.

During a five-year period, 178 patients had the intraaortic balloon pump (IABP) inserted for circulatory support. The IABP was used most frequently as an adjunct for weaning patients from cardiopulmonary bypass. Seventy-seven of 103 patients (75%) were successfully weaned from cardiopulmonary bypass with the IABP, and 36 of them (35%) ultimately survived hospitalization. Other indications for the IABP included circulatory support before cardiac operation (16 patients), operative prophylaxis in high-rish patients (13), and postoperative hemodynamic support (23). Additionally, the IABP was placed in 23 patients who did not undergo cardiac operation. The incidence of IABP-related complications was significantly less when the IABP was inserted through the ascending aorta (4%) intraoperatively compared with the femoral or iliac artery (25%) (p less than 0.05). This was due primarily to vascular complications and groin wound infections that occurred with the femoral or iliac artery approach. IABP-related spinal cord paralysis developed in 3 patients (1.7%). We conclude that the IABP is an effective support device for treating patients with left ventricular failure particularly when weaning them from cardiopulmonary bypass. However, the risk of complications, including paraplegia, must be carefully weighed when use of the IABP is considered, especially in situations in which its efficacy is less clear.

Early recognition of surgically correctable causes of excessive mediastinal bleeding after coronary artery bypass graft surgery.

In an attempt to establish criteria to enable recognition of patients with surgically correctable causes of excessive mediastinal bleeding, 250 patients undergoing coronary artery bypass graft surgery were reviewed. Ten (4 percent) required reexploration for excessive postoperative mediastinal bleeding and were compared with 95 consecutive control patients. There were no statistically significant differences in preoperative coagulation studies, use of aspirin or warfarin, number of vessels bypassed or bypass time. Mean mediastinal blood loss was statistically greater (p less than 0.001) in the reexploration group for the first 8 hours of the postoperative period than in the control group. Mean heterologous blood transfusion was 8.4 units in the reexploration group compared with 1.3 units in the control group. Based on analysis of the differences in mediastinal bleeding rates in the control and reexploration groups, we conclude that after coronary artery bypass graft surgery postoperative mediastinal bleeding of greater than 300 ml in the 1st hour, greater than 250 ml in the 2nd hours, and greater than 150 ml/hour thereafter suggests the presence of a surgically correctable lesion.

Propranolol for prevention of postoperative cardiac arrhythmias: a randomized study.

Two hundred twenty-three patients were randomly selected to receive propranolol, 10 mg orally every 6 hours, or to serve as controls after coronary artery bypass grafting. The study began at the time of discharge from the intensive care unit. Patients were ineligible if they had cardiac arrhythmias while in the intensive care unit, low cardiac output requiring catecholamine support, or bradycardia requiring a pacemaker. In the control group, cardiac arrhythmias for which treatment was necessary developed in 31 of 136 patients (23%), atrial fibrillation or flutter in 24 patients (18%), and ventricular arrhythmias in 7 (5%). In the group receiving propranolol, cardiac arrhythmias requiring treatment developed in 9 of 87 patients (10%), atrial fibrillation or flutter in 7 (8%), and ventricular arrhythmias in 2 (2%). The difference in frequency with which cardiac arrhythmias occurred between the two groups is significantly different (p less than 0.05). We conclude that propranolol is effective in the prevention of cardiac arrhythmias following coronary artery bypass grafting.

Bradykinin, plasma protein fraction, and hypotension.

A directive from the Food and Drug Administration indicates that the use of plasma protein fraction (PPF) is contraindicated during cardiopulmonary bypass because of possible hypotension. Bradykinin has been implicated as the cause of this hypotension. Bradykinin levels were measured by radioimmunoassay in PPF and in 5% albumin and were found to be consistently elevated in the former and occasionally in the latter. The addition of PPF to pump primes resulted in significantly elevated levels of bradykinin, which rapidly cleared, indicating that extrapulmonary sites of bradykinin inactivation were efficient. The potential hypotensive effect of PPF was observed by determining the change in mean perfusion pressure in two groups of patients: one group with a 3,000 ml crystalloid prime and the other with a prime of 2,000 ml of crystalloid and 1,000 ml of PPF. There was no significant difference in the perfusion pressure between the two groups at any point, and the hypotensive effects seen in both groups were readily treated, suggesting that the directive against the use of PPF during cardiopulmonary bypass may be unnecessarily restrictive.

Retinal arteriolar changes as an indicator of coronary artery disease.

Funduscopic examination was performed in 70 non diabetic, nonhypertensive patients without valvular heart disease undergoing coronary angiography for evaluation of chest pain syndromes to determine if retinal arteriolar changes could reliably predict presence of coronary artery disease. Retinal arteriolar changes were graded with respect to light reflex, vessel caliber, arteriovenous crossing defects, and vessel tortuosity without knowledge of angiographic findings. Each coronary vessel was graded with respect to its most occlusive lesion by angiography; coronary index was derived for each patient without knowledge of eye findings. Abnormal light reflex changes were the most sensitive indicators of presence and extent of coronary artery disease. Abnormal vessel tortuosity and decreased caliber were less sensitive but more specific; their presence also suggested more extensive coronary lesions. Thus, funduscopic examination demonstrating specific retinal arteriolar lesions may indicate presence of coronary artery disease and may correlate with extent of lesions in selected patients.

Tricuspid valvular incompetence and rupture of the ventricular septum caused by nonpenetrating trauma.

A young adult involved in an automobile accident had tricuspid valvular incompetence and rupture of the ventricular septum owing to blunt trauma. He had a successful repair of the ventricular septal defect and replacement of the tricuspid valve. Tricuspid valvular incompetence owing to nonpenetrating trauma is uncommon. Blunt trauma resulting in rupture of the ventricular septum is rare. Rupture of the membranous portion of the ventricular spetum is extremely rare. This is the first report of a patient having a combination of these lesions.