Topical cardiac hypothermia in patients with coronary disease. An unnecessary adjunct to cardioplegic protection and cause of pulmonary morbidity.

This retrospective analysis tests the hypothesis that topical cardiac hypothermia is an unnecessary adjunct to intraoperative myocardial protection and an avoidable cause of pulmonary morbidity in patients with coronary disease receiving blood cardioplegia. The hospital records of 150 nonrandomized consecutive patients undergoing elective and emergency isolated coronary revascularization were reviewed. All patients received multidose cold blood cardioplegia followed by warm blood cardioplegic reperfusion distributed through grafts. Fifty patients received iced slush, 50 received topical 4 degrees C saline, and no topical cooling was used in 50 others. Patients groups were comparable in number of grafts (3.7 versus 3.5 versus 3.5) and crossclamp time (61 versus 62 versus 61 minutes). More emergency operations were performed in the patients receiving no topical hypothermia (12/50 versus 8/50 versus 7/50). Postoperative x-ray films were reviewed by a radiologist who did not know of patient grouping. Postoperative results were comparable in hemodynamics, inotropic requirements (10/50 ice versus 8/50 saline versus 5/50 no cooling), myocardial infarction (1/50 versus 2/50 versus 2/50), and enzymes (aspartate aminotransferase myocardial band creatine kinase). No patient died. Ice topical hypothermia (versus no topical cooling) was associated with more left pleural effusions (25/50 versus 9/50; p less than 0.05), atelectasis (33/50 versus 18/50; p less than 0.05), elevated left hemidiaphragms (13/50 versus 0/50; p less than 0.05), and longer postoperative hospitalization (11.2 versus 8.5 days; p less than 0.05). Topical 4 degrees C saline reduced diaphragmatic elevation and pleural effusion (versus topical ice) but was associated with more atelectasis (34/50 versus 18/50; p less than 0.05) than no topical cooling. These data suggest that routine topical hypothermia is an unnecessary adjunct to blood cardioplegic protection in patients with coronary disease, since supplemental topical cooling does not improve postoperative hemodynamics or reduce inotropic requirements, enzyme release, or prevalence of postoperative myocardial infarction, and it increases pulmonary morbidity, which can be reduced by its avoidance.

Retrograde aortic dissection during cardiopulmonary bypass: "nonoperative" management.

Seven patients are reported in whom retrograde aortic dissection occurred, 2 during valve replacement and 5 during coronary artery bypass, among 770 patients perfused through the common femoral artery. Successful management included : (1) immediate cessation of cardiopulmonary bypass; (2) removal of the arterial cannula and its replacement in the ascending aorta, usually through both lumens of the dissection; (3) completion of the operation by suturing the proximal ends of saphenous vein grafts to both lumens of the dissection in the ascending aorta; and (4) no treatment of the dissection itself. One patient died of other causes 30 days postoperatively. Follow-up from 2 to 3 1/2 years in 6 long-term survivors has revealed no complications related to the dissection. Saphenous vein graft function is apparently satisfactory.

Renal cell carcinoma presenting as right atrial tumor with successful removal using cardiopulmonary bypass.

A 58-year-old male presented with signs and symptoms of right sided heart failure. Diagnostic evaluation revealed a right renal cell carcinoma with extension into the vena cava and right atrium. Surgical management included radical right nephrectomy with retroperitoneal lymph node dissection, inferior vena caval resection, and removal of the intra-atrial tumor thrombus using a cardiopulmonary bypass. Two years after surgery the patient is alive and well with no evidence of recurrent disease.