Internal mammary artery harvesting using the harmonic scalpel.

Internal mammary artery (IMA) harvesting using the harmonic scalpel (HS) was recently introduced. We studied 541 IMAs harvested by the same surgeon through a standard median sternotomy in 472 coronary bypass patients; 252 (47%) with the HS, while 289 (53%) were with electrocautery (EC). Patient demographics included mean ages: 67 years HS vs. 65 years EC (p = NS); male:female ratio: 3:1; and insulin dependent diabetes mellitus (IDDM): 11% HS vs. 12.5% EC (NS). Mean ultrasonic IMA flow at a mean SBP of 70 mm Hg in 10 consecutive patients of each group were: preharvest, HS 11.9 +/- 2.3 ml/min vs. EC 8.5 +/- 1.6 ml/min (p = 0.256); postharvest, HS 35.7 +/- 10.7 ml/min vs. EC 22 +/- 2.9 ml/min (0.235); and postcardiopulmonary bypass (post-CPB), HS 47.8 +/- 6.2 ml/min vs. EC 41.7 +/- 2.5 ml/min (0.381). Histologic samples of 50 consecutive IMAs showed no evidence of vessel injury in either group. Clinical results revealed postoperative bleeding in 6/217 (2.7%) HS vs. 7/255 (2.7%) EC (p = 0.783), none attributed to bleeding from the IMA; phrenic paresis: 0/217 in HS but 1/255 (0.4%) in EC (p = 0.960); sternal wound infection: 5/217 (2.3%) HS vs. 6/255 (2.4%) EC (p = 0.787); postoperative IABP: 6/217 (2.7%) HS vs. 5/255 (2%) EC (p = 0.859); mortality: 2/217 (0.9%) HS vs. 2/255 (0.8%) EC (p = 0.710). Hemodynamic, histologic, and clinical results were comparable in both groups. The authors believe the HS is safe and effective for IMA harvesting.

The internal ventricular venting loop catheter. A new, simplified, single cannulation approach for a ventricular assist system.

The internal ventricular venting loop (IVVL) catheter is a coaxial, two lumen, bidirectional flow cannula introduced peripherally and advanced intraluminally to the pulmonary artery by its flow directed, balloon tipped inner tubing in a right ventricular assist system (RVAS), or to the left ventricle over a guide wire under fluoroscopy in a left ventricular assist system (LVAS). Its use was successfully tested in six acute canine experiments using a small IVVL catheter. Hemodynamic responses to increasing roller pump flow rates, to a maximum of 1 L/min, were initially measured. Then, hemodynamic changes to 600 ml/min, after left anterior descending artery ligation (in IVVL-LVAS) and 300 ml/min after right coronary artery ligation (in IVVL-RVAS) were regularly recorded every 15 min until cardiac arrest. The IVVL-LVAS was able to significantly decrease the pulmonary capillary wedge pressure, while the IVVL-RVAS was able to significantly decrease the central venous pressure. The IVVL system was able to partially unload the ventricles and restore about 33-60% of the cardiac output. However, it could not effectively support the heart during arrest. Thus, the IVVL catheter can facilitate simple and effective single cannulation for either RVAS or LVAS. This approach may enable ordinary cardiac centers to make use of already available blood pumps for temporary, inexpensive, and less invasive application of partially assisted circulation when intra aortic balloon pump assistance fails.

Mediastinal hematoma mimicking aortic rupture.

The case of a child who fell a relatively short distance and had clinical and x-ray findings consistent with a ruptured aorta is presented. At surgery, a mediastinal hematoma was found. Diagnostic and therapeutic implications are discussed.

Aortocoronary bypass surgery: a 7-year follow-up.

Follow-up of 748 consecutive patients who underwent aortocoronary artery bypass grafts was obtained for 5 to 94 months (average, 59 months). Operative mortality of 2.5% did not vary with number of vessels bypassed. There was a linear 3.5% annual recurrence rate of angina, and average annual late infarction rate of 1.4%. The cumulative survival rates did not differ for the number of grafts performed or for men and women, but did differ for left main coronary stenosis and impaired ejection fractions. The late cumulative survival rates for the entire group approached those of the general U.S. population.

Combined left ventricular aneurysm and coronary artery bypass surgery: long-term results of 100 consecutive patients.

Forty-four percent of 2,367 patients who had operations for the complications of coronary atherosclerosis between 1971 and 1977 were noted to have major left ventricular wall motion abnormalities. Of this group, 100 patients required left ventricular aneurysm resections or plications (4.2%). There were 85 men and 15 women. Their average age was 52 years (range, 30 to 68 years). Concomitant coronary artery bypass grafting was required in 95 patients. The operative mortality was 7% and the actuarial survival at six years was 78%. Patients were followed for an average of 31 months (range, 3 to 72 months). Eighty-eight percent of the survivors had excellent or good results with improvement of their functional status to the New York Heart Association classes I and II. Age, congestive heart failure, and poor residual left ventricular function had an adverse effect on the outcome of these patients. Concomitant coronary artery bypass grafting seems to have favorably influenced their outcome and functional recovery. Surgical judgment is of great importance in selecting which patients require left ventricular aneurysm resection.

Fatal peritonitis after massive blood transfusion: case report.

A case is presented in which successful repair of a superior vena cava gunshot wound was followed by death due to peritonitis. A mild case of endometritis progressed to generalized peritonitis after the patient's immune defenses were compromised by massive transfusion of banked blood. Clinicopathologic correlation is provided.