Malignant renal tumor with extension to the inferior vena cava.

BACKGROUND: Management of malignant renal tumors involving the inferior vena cava (IVC) depends on tumor extension within the cava. METHODS: Of 295 patients treated for renal cancer, propagation of tumor mass through the renal vein to IVC was seen in 22 (7%) patients. Cephalad extension of the tumor was suprarenal: infrahepatic in 12, retrohepatic in 6, and within the right atrium in 4 patients. All patients had radical nephrectomy, cavotomy, and complete resection of tumors except 1 with diffuse peritoneal metastasis. RESULTS: Twenty-one patients had curative resections. No operative deaths and no instances of pulmonary embolism or exsanguination occurred. Seventeen patients were alive at 2 years and 12 at 5 years, resulting in 77% and 55% survival rates, respectively. CONCLUSIONS: An aggressive approach for vena cava involvement from malignant renal neoplasms resulted in prevention of tumor embolus, minimization of blood loss, and maintenance of venous return to the heart.

Downregulation of right ventricular phosphodiesterase PDE-3A mRNA and protein before the development of canine heart failure.

Phosphodiesterase III (PDE-3) inhibitors are inotropes used to treat congestive heart failure (HF). Previous studies showed PDE-3A mRNA levels were reduced in the left ventricle (LV) in dogs subjected to pacing-induced HF. The present study evaluated a time-course for RV-specific changes in PDE-3A mRNAs and proteins after pacing for 3 wk (n = 4) or in HF (4-5 wk; n = 4-6). Total RNA from LV/RV tissues was isolated for Northern analyses; cytosolic and microsomal proteins were prepared for PDE-3A immunoblots. PDE-3A mRNAs (7-8 and 10 kb) were normalized against glyceraldehyde-3-phosphodehydrogenase (GAPDH) or ribosomal 18s with similar results. PDE-3A/GAPDH ratios in 3 wk were unchanged in LV, but significantly (p < 0.05) reduced by 48% in RV vs unpaced controls (n = 8). In contrast, PDE-3A (7-8 kb)/GAPDH ratios were significantly reduced in HF by 50-59% in both ventricles. Consistent with mRNA levels, significant reductions in microsomal 135 kDa (93-96%) and cytosolic 120 kDa PDE-3A (57-69%) were seen in both ventricles in HF or in the RV at 3 wk; an LV-specific reduction (50%) in cytosolic 80 kDa PDE-3A in HF was also detected. In summary, RV-specific downregulation of PDE-3A mRNA/protein(s) at 3 wk suggests that hemodynamic rather than humoral mechanisms are responsible, and provides a molecular basis for the limited efficacy of milrinone in the progression of HF.

Development of decompensated dilated cardiomyopathy is associated with decreased gene expression and activity of the milrinone-sensitive cAMP phosphodiesterase PDE3A.

BACKGROUND: Phosphodiesterase III (PDE3) inhibitors are inotropic agents used to treat congestive heart failure (CHF) and are less effective in patients with severe CHF. Little is known about relative changes in PDE3 activity or gene expression during the evolution of cardiomyopathy. METHODS AND RESULTS: In the present study, we evaluated temporal changes in PDE3A gene expression before and after pacing-induced CHF in nine mongrel dogs. Three weeks of left ventricular (LV) pacing produced LV end-diastolic pressures of 15+/-1.7 mm Hg, whereas overt CHF at 4 to 5 weeks was associated with LV end-diastolic pressures of 24+/-1.7 mm Hg; prepacing values were 6.6+/-0.6 mm Hg. Total RNA isolated from LV tissues was analyzed on Northern blots; 10 unpaced normal hearts served as tissue controls. Signals for PDE3A mRNAs (7, 8, and 10 kb) or PDE4D (7.6 kb) were normalized against glyceraldehyde-3-phosphate dehydrogenase (GAPDH) or ribosomal 18S RNA. Before the onset of CHF, PDE3A/GAPDH ratios were not different between the control and 3-week paced groups. In contrast, all PDE3A/GAPDH ratios were selectively reduced by 52%, and PDE3A/18S was reduced by 70% (P<.05) in CHF; PDE4D/GAPDH (or 18S) was unchanged. LV tissues from four control and four CHF dogs were also processed to isolate cytosolic and microsomal membrane protein for cAMP PDE3 activity assays. CHF was associated with a significant 54% reduction (P<.05) in microsomal but not cytosolic PDE3 activity. CONCLUSIONS: Selective downregulation of PDE3A may account in part for the ineffectiveness of milrinone in the treatment of severe CHF.

Immediate-early gene expression in human saphenous veins harvested during coronary artery bypass graft operations.

Saphenous vein graft occlusion is a common late complication of coronary bypass grafting. Intimal smooth muscle cell hyperplasia is a component of this pathobiology, but the underlying molecular events are poorly understood. Immediate-early genes are activated shortly after growth stimulation and subserve cellular functions, which may contribute to intimal smooth muscle cell accumulation. In the present study, human saphenous vein grafts were harvested with minimal manipulation during coronary bypass and processed for isolation of total ribonucleic acid to examine change in immediate-early gene expression of messenger ribonucleic acid by Northern blotting techniques. Thirty saphenous vein grafts were incubated at 4 degrees C in Dulbecco's modified Eagle media from 30 minutes to 10 hours. The messenger ribonucleic acids for immediate-early genes c-fos and c-myc were weak or undetectable in controls but were increased (> 10 times controls) within 1 hour (c-fos) and persisted for at least 6 hours (c-myc) after harvest. Our results demonstrate, for the first time in human vascular tissue, incipient immediate-early gene induction. This information may lead to molecular therapies to control saphenous vein graft disease.

Unplanned extubation in the intensive care unit: a quality-of-care concern.

A 1-month prospective quality improvement audit was performed to determine the incidence of self-extubation in the intensive care units (ICUs) at the Westchester County Medical Center (WCMC), a 625-bed tertiary care hospital with 92 intensive care beds in 11 ICUs. During the 1-month study period, there were seven unplanned extubations in six of 121 intubated patients, or one unplanned extubation for every 136 patient-ventilator days. Based on the initial review, a corrective action plan was initiated that consisted of education of nurses and house staff about the problem of unplanned extubation, daily assessment on rounds of patient risk of unplanned extubation, and careful documentation of any episodes of unplanned extubation. A 5-month follow-up review identified 12 unplanned extubations in 11 patients, which resulted in a reduced rate of one unplanned extubation per 455 patient-ventilator days. Risk factors for unplanned extubation included documented anxiety, routine care intervention, and a history of previous unplanned extubation. Unplanned extubation can be a serious complication associated with mortality and therefore is a quality-of-care concern. However, the majority of patients with this complication did well and were discharged from the hospital. The incidence of unplanned extubation can be reduced but not eliminated by a program of education and attention to risk factors for unplanned extubation.

Experience with the Mitroflow aortic bioprosthesis.

From October 1985 to May 1990, the Mitroflow bovine pericardial valve was placed in the aortic position in 168 patients (97 men, 71 women) with a mean age of 69.7 years. Eighty-nine patients had isolated aortic valve replacement, and 79 had aortic valve replacement and additional procedures. Follow-up over 7 1/2 years includes 781 patient years (426 for isolated aortic valve replacement). Mean follow-up time is 56 months. Peak-to-peak gradients (in millimeters of mercury) measured in the intraoperative period averaged 11.0 +/- 8.7, 11.8 +/- 10.8, and 8.6 +/- 8.2 for 19 mm, 21 mm, and 23 mm valves, respectively. Hospital mortality was 7.3% (14 patients); all deaths were non-valve related. Late mortality of 20.1% in 31 patients resulted from cardiac failure (n = 8), sepsis (n = 4), valve reoperation (n = 1), non-cardiac causes (n = 15) and sudden, unknown causes (n = 3). Fifteen thromboembolic episodes occurred, but only three late thromboembolic episodes occurred in isolated aortic valve replacement without other risk factors. Four early and four late episodes of endocarditis occurred. Seven patients had clinical valve dysfunction, and five others required reoperation for structural deterioration, with one death. At 94 months, overall survival was 64% +/- 5%. Freedom from thromboembolic episode was 87% +/- 3% and 90% +/- 4% for isolated aortic valve replacement. Freedom from combined reoperation or clinical dysfunction was 75% +/- 8%: 64% +/- 15% for those under 70 years of age, and 87% +/- 7% for those 70 years of age and older. The valve has favorable hemodynamics. Durability begins to decline during the sixth year after implantation, possibly at a slower rate in patients older than 70 years of age.

Aortic annular abscess complicating prosthetic valve endocarditis with group G streptococcus: detection during life with transesophageal echocardiography.

Infection with group G streptococcus is an unusual but virulent cause of endocarditis. Aortitis and abscess formation due to this organism have been described in one previous report, but only at necropsy. We present here a patient with group G streptococcal endocarditis and aortic annular abscess diagnosed during life by transesophageal echocardiography, leading to successful surgical intervention.

Primary cardiac tumors. Diagnosis and management in 14 cases.

In our experience over a 10-year period at Westchester County Medical Center (Valhalla, NY), we diagnosed 11 left atrial myxomas and three primary cardiac malignancies in ten females and four males, aged 18-74 years. Two-dimensional echocardiography enabled the correct diagnosis of these lesions. Detailed characteristics of the cardiac tumors were provided by magnetic resonance imaging (MRI) scanning in five patients. Two of three malignancies were only biopsied; the myxomas were completely excised. We emphasized removal of tumor and its attachments to the atrial wall, accomplished by left or biatrial incision, full-thickness excision of the area of attachment, and pericardial patch closure of the atrial or free-wall defects. Associated procedures included mitral valve repair (three) and coronary artery bypass grafting (two). There was no mortality associated with the surgery. Two patients with malignancy died three and 36 months after surgery; a third is alive at 30 months after surgery. No patients with myxoma has had recurrence from 16 to 100 months. Preoperative diagnosis of cardiac tumors is enhanced by MRI scanning and may help in planning the surgical procedure. Complete and timely removal of these tumors contributes to long-standing patient survival.

Use of the centrifugal flow pump for vena caval shunting.

We have used the Bio-Medicus centrifugal flow pump for vena cava shunting during surgical resection of renal cell carcinoma with extension of the tumor into the inferior vena cava. The active shunt can provide optimal blood return to the heart to promote hemodynamic stability, help provide an isolated field for resection of the involved kidney and its tumor extension into the vena cava, and avoid use of full-dose heparin to minimize blood loss in this extensive operation.

MR imaging in the definition of coronary artery anomalies.

Coronary angiography remains the standard imaging technique to study coronary artery anatomy. Coronary artery aneurysms and fistulas are often incompletely visualized with routine angiography. Magnetic resonance (MR) imaging of such coronary anomalies is presented. The MR images improve the preoperative assessment of patients with coronary artery aneurysms and fistulas.

Postoperative evaluation of ascending aortic prosthetic conduits by magnetic resonance imaging.

Operative repair of ascending thoracic aortic dissection and aneurysm often involves the placement of prosthetic aortic conduits and stents with wrapping of the native aorta around the prosthetic device. Postoperative assessment has been clinical because of the absence of an adequate noninvasive imaging modality and a reluctance to perform invasive contrast aortography. Magnetic resonance imaging was performed on ten patients after operative placement of a prosthetic ascending aortic graft. The MR images were reviewed and a grading system was devised based on appearance of the operative site. An increase in MR signal was noted in some patients between the graft and wrapped native vessel. In 20 percent of patients vascular lumen compromise was noted. Magnetic resonance imaging offers a noninvasive technique to assess postoperative complications and offers a viable alternative to invasive contrast aortography.

Simplified method for reoperation on the mitral valve.

Reoperation on the mitral valve is becoming more common because of the degeneration of bioprosthetic valves, endocarditis, and malfunction or thrombosis of mechanical valves. We advocate a technique that transforms a technically difficult operation into one that is much less tedious, time-consuming, and dangerous than reopening a sternal-split operative site the second, third, or fourth time. Favorable experience in 11 patients using right anterolateral thoracotomy without aortic or right atrial cannulation and without aortic cross-clamping or cardioplegia is presented.

Coronary revascularization in young patients.

From 1978 to 1982, 92 of our 1704 patients undergoing coronary bypass surgery were 40 years of age or younger. Eighty-six were male and six were female. The main indications for surgery were refractory angina and unstable angina. A family history of heart disease, smoking, and hypertension were major risk factors. The majority of patients had triple vessel disease, and six had left main lesions. Left ventricular function was moderately or severely impaired in 24. Coronary revascularization was performed with internal mammary and saphenous vein conduits, with a mean of 3.7 grafts per patient (range, 1 to 7). There was no operative mortality, but one patient required an intraaortic balloon pump. Perioperative infarction determined by Q waves occurred in one patient, while eight had enzymatic evidence of infarction. Late follow-up to 60 months showed three late deaths of cardiac origin. Eighty-three survivors were greatly improved, and 50 were asymptomatic. Sixty-five patients returned to work. Seventy percent of smokers stopped smoking; half the patients exercised regularly, and half maintained dietary modifications. Coronary bypass grafting is an effective rehabilitation procedure in the young. Long-term attention to risk factors and life style is required to maintain a beneficial outcome.

Delayed sternal closure as a safe adjunct to support biventricular failure after open heart surgery.

Over a four-year period, 22 patients of 2495 undergoing open heart surgery sustained severe biventricular failure (BVF) and would not tolerate primary sternal closure. Reasons for BVF included intraoperative injury, perioperative infarction, global dysfunction, cardiopulmonary edema, and intractable arrhythmia. Mechanical assist devices were required in nine patients. Average cardiac index fell to 1.1 L/min/m2 with attempts to close the chest, then stabilized at 1.9 with the sternum open and only soft tissue closed. After 3 to 11 days, cardiac index rose to 2.5 when assist devices were removed, inotropic agents decreased, and the sternum closed. Three early deaths (5-12 days) were caused by progressive biventricular failure. Five later deaths (19-64 days) were associated with renal and respiratory failure, superinfection, and sepsis. All of these required tracheostomy. Survival of 14 patients was not related to early low cardiac output, preoperative status, timing of sternal closure, or age, but was associated with early recovery of respiratory function without need for tracheostomy, avoidance of renal failure, and satisfactory alimentation. Sternal infection occurred in three patients, resulting in one death. The hospital stay ranged from 12 to 230 days. There was one death resulting from respiratory failure 14 months postoperatively. Our findings show that delayed sternal closure lessens early cardiac instability during BVF, helps allow recovery, and does not produce long-term disability.

Endothelial loss due to leukocytes in canine experimental vein-to-artery grafts.

Vein-to-artery grafts develop areas of endothelial loss with fibrin and leukocytes which lead to early thrombosis and may lead to subsequent atherosclerosis of the graft. En face monolayers were prepared which removed greater than 90% of vascular intima. Unevenly distributed leukocytes and endothelial cells were counted using a standardized sampling of calibrated oil immersion fields of 0.01 mm2. Nongrafted veins had 14 +/- 1 evenly arranged endothelial cells per field without gaps or leukocytes, while 10-min grafts had 13 +/- 2 with rare leukocytes. Four-hour grafts from normal dogs had 9 +/- 2 endothelial cells with gaps and 97 +/- 37 neutrophils and 44 +/- 25 monocytes. Leukopenic dogs (vinblastine-treated) had normal numbers of endothelial cells (14 +/- 1) with scanty leukocytes. We conclude that leukocytes cause endothelial loss in vein-to-artery grafts that can be prevented by intense leukopenia. This may lead to practical approaches to protecting such grafts in humans.

The metabolic cost of breathing in critical surgical patients.

Twenty ventilator-dependent patients, 14 male and six female, age 47.9 +/- 14, status post polytrauma (14), emergency surgery (three), and coronary artery bypass (three) were evaluated to compare measured energy expenditure (MEE) between the intermittent mandatory ventilation mode (IMV) and assist mode ventilation (AMV) utilizing indirect calorimetry. The MEE was then compared to the predicted basal energy expenditure (PEE) utilizing the Harris-Benedict equation (HBE) and appropriate correction factors dependent on disease and injury status (mean 1.65 +/- 0.24). The mean oxygen consumption (VO2) (IMV) was 347.5 +/- 54.6 ml/min; (VO2) (AMV) was 307.1 +/- 51.4 ml/min (p less than 0.001). The mean MEE (IMV) was 2,380 +/- 369 kcal/day; MEE (AMV) was 2,128 +/- 342 kcal/day (p less than 0.05). The mean predicted energy expenditure (PEE) was 2,731 +/- 416 kcal/day. The IMV mode required 11.6% more pulmonary work when compared to AMV (VO2 IMV - VO2 AMV). The PEE overestimated caloric needs in ventilator-dependent patients by 12.8% on IMV and 22.1% on AMV. The MEE (IMV) required 10.7% more energy than MEE (AMV). Assist mode ventilation resulted in decreased work of breathing and decreased energy expenditure, and the (HBE) inaccurately predicted caloric needs in ventilator dependent patients.

Hemodynamic comparison of albumin and hydroxyethyl starch in postoperative cardiac surgery patients.

The hemodynamic effects of 2 plasma volume expanders were compared in postoperative open heart surgery patients. Albumin 5% (A) or hydroxyethyl starch 6% (HES) solutions were infused according to indications based on cardiac index (CI) and pulmonary wedge pressure (WP), and their effects evaluated by physiologic profile measurements. Both groups demonstrated significant increases with volume infusion in CI (A from 2.37 to 2.84; HES from 1.97 to 2.49 L/min X m2) and WP (A from 9.4 to 13.7 mm Hg; HES from 11.9 to 13.2 mm Hg). Stroke index and stroke work increased similarly. Mean systemic arterial pressure (MAP) and mean pulmonary arterial pressure (MPAP) remained unchanged. No significant difference for any variable was demonstrated between the A and HES groups. In the volume used, from 250 to 750 ml, HES caused no bleeding abnormalities. HES is as effective as A as a plasma volume expander in postoperative cardiac surgery patients.

Results of combined valvular and myocardial revascularization operations.

A total of 105 patients underwent combined coronary artery and valvular operations. Sixty-six had combined coronary artery bypass grafting (CABG) and aortic valve replacement (AV), 28 had CABG and mitral valve operations (MV), and 11 patients had CABG and double or triple valve operations (DTV). An average of 3.0 bypasses was done, range one to seven. These patients were compared to a similar group of patients who underwent valve replacement(s) only, without CABG. Bypass time was increased for the combined groups, as was ischemic cross-clamp time. Early mortality was 3.0% AV, 3.5% MV, and 9.1% DTV in the combined groups and 1% in the valve only groups. The higher mortality for the combined groups was almost entirely due to the 23% mortality in women over 70 years of age. Perioperative myocardial infarction (MI) was higher in the combined groups (5% MI, 9% probable MI versus 2.9% MI, 4.1% probable MI). All survivors were in improved clinical condition and free of angina. Mortality and improvement were unrelated to perioperative infarction. The small increase in risk compared to the significant improvement from the combined approach has led to the following principles: coronary arteriography on all adult patients requiring valvular operations; bypass of all significant coronary lesions; restoration of valvular function and hemodynamics; and myocardial preservation with cold cardioplegia during a single period of cross clamping, topical cold, and systemic hypothermia.

Durability of measured mitral annuloplasty: seventeen-year study.

This report describes the technique and results of measured mitral annuloplasty performed in 196 patients having isolated mitral valve disease during the 17 years between January, 1961, and January, 1978. These patients represent 35% of all of those operated upon for isolated mitral valve disease during this period. Ages ranged from 3 to 70 years. Annuloplasty was performed in 115 patients and both commissurotomy and annuloplasty in another 81 patients. The operative mortality rate was 4.5% and the late mortality rate 8.7%. There were six arterial embolic episodes during the 17 years. Reoperation was required in 8% with another repair of the valve being possible in one third of them. This study suggests that measured repair of mitral regurgitation resulted in lower operative mortality, late mortality, and incidence of embolization when contrasted with mitral valve replacement. This operation appears to be the preferred procedure for certain subsets of patients (1) who require operation during infancy or childhood, including during active carditis; (2) who require operation during the childbearing age; and (3) in whom anticoagulation poses a severe threat to life or quality of life.