Ten years of experience with the modified Ross procedure.

BACKGROUND: To assess the full root modification of the Ross procedure, we examined operative and long-term results. METHODS: We retrospectively reviewed 145 patients (118 men and 27 women) operated on from March 1987 through April 1997. Ages ranged from 17 to 68 years. Primary diagnosis was aortic stenosis in 43 patients (29.6%) and aortic regurgitation in 62 patients (42.8%). There was mixed disease (stenosis and regurgitation) in 40 patients (29.6%) of whom the vast majority had predominant stenosis. RESULTS: Early death was 7 of 145 patients (4.8%). Twelve patients had 14 significant complications (8.5%). There were four late deaths. Overall patient survival is 90.5% +/- 3.1% at 5 years and 84.5% +/- 14.1% at 7 years. Endocarditis occurred in three patients-two on the autograft and one on the pulmonary homograft. Three patients had cerebrovascular accidents. In 5 of 132 patients (3.8%) reoperations were required on the autograft. Freedom from autograft reoperation was 93.9% +/- 3.1% at 5 years and 88.6% +/- 6.4% at 7 years. Echocardiographic follow-up reveals more than mild aortic regurgitation in only nine patients, including the five patients in whom reoperations were required. Seven of 11 patients with active endocarditis at the time of the operation had adverse outcomes. CONCLUSIONS: Ten years' experience with the modified Ross procedure has shown excellent results with regard to short- and long-term morbidity and death. It is the procedure of choice for young patients who need aortic valve replacement but should be used with caution in the setting of active endocarditis.

Routine myocardial revascularization with the radial artery: a multicenter experience.

BACKGROUND: Current literature documents use of the radial artery (RA) for myocardial revascularization only as an alternative conduit in cases where the saphenous veins have been previously harvested or are unsuitable for use. Large-scale routine clinical use of the RA as the conduit of choice has not been reported. METHODS: This prospective study evaluated the harvest of the RA from 933 patients and the subsequent use of the conduit as a preferred coronary artery bypass graft second only to the left internal thoracic artery in 930 of these patients. RESULTS: Unilateral RA harvest was performed in 786 patients and 147 patients had bilateral RA harvest. A total of 1080 RAs were harvested; 214 (19.8%) originated from the dominant forearm. There was a mean of 3.30+/-0.93 grafts per patient of which 2.43+/-0.83 were arterial grafts. The mean number of RA grafts was 1.43+/-0.53. Operative mortality was 2.3% with none due to the RA graft(s). There was no ischemia nor motor dysfunction in the operated hands. Thirty-two (3.4%) patients experienced transient thenar dysesthesia that resolved in 1 day to 6 weeks. CONCLUSIONS: Our results demonstrate that routine total or near total arterial myocardial revascularization may be achieved safely and effectively with the use of one or both RAs in conjunction with the internal thoracic artery.

Retinal artery embolization: a rare presentation of calcific aortic stenosis.

Retinal artery embolization is an unusual but serious complication of calcific aortic stenosis. However, it is rare for retinal embolization to be the presenting feature of aortic stenosis. This report describes a young patient who presented with an acute retinal artery occlusion secondary to calcific aortic valve disease, and discusses the rationale for early surgical intervention.

Multicentric granular cell tumor of the heart presenting with aortic dissection.

A 43-year-old woman with a history of cutaneous granular cell tumor presented with severe aortic regurgitation due to a type A aortic dissection. During repair, multiple masses were found on the surface of the heart, which later were identified to be granular cell tumor. We present an extremely rare case of multicentric granular cell tumor of the skin and heart, manifested over a 23-year period.

Successful repair of a submitral left ventricular infected pseudoaneurysm.

Aneurysms of the left ventricle may be congenital or may occur after a myocardial infarction, trauma, or endocarditis. Infective endocarditis can cause destructive injury to the heart in various ways. This report describes the formation of an aneurysm of the left ventricle from trauma of a bacterial vegetation of the mitral valve. Early recognition by echocardiography and magnetic resonance imaging led to successful repair and prevented a catastrophic result.

Mycotic aneurysm of the aortic arch with aortoesophageal fistula.

An elderly man presented with an aortoesophageal fistula (AEF) and underwent resection of a mycotic aneurysm of the aortic arch. After an initial success, the patient ultimately succumbed to mediastinal sepsis. The various approaches to combined aortic and esophageal pathology are presented with the recommendation for aortic replacement along with early removal of mediastinal contamination.

Aspirin anticoagulation in children with mechanical aortic valves.

The optimal method of anticoagulation in children with mechanical heart valves is controversial. Between 1975 and 1986, aspirin or aspirin with dipyridamole has been used for anticoagulation in children receiving a mechanical aortic valve at the University of California, San Francisco. Fifty-one patients (ages 1 to 23 years, mean 12.9 years) were treated with aspirin (n = 45) or aspirin with dipyridamole (n = 6) and observed a mean of 36.5 months (range 3 to 100 months). There were four late deaths: two from endocarditis and two from other medical problems, but none related to thrombosis or embolus. Follow-up was accomplished by direct contact with the patient, parent, or referring physician. Two patients (3.9%) were lost to late follow-up. One minor neurologic event occurred perioperatively and resolved spontaneously. There were no postoperative thromboembolic events. Eleven asymptomatic children were recently studied by magnetic resonance imaging or computed axial tomography of the brain and had no evidence of prior silent cerebral thromboembolic defects. There were four patients (5.9%) who had minor hemorrhagic complications: Three patients had nosebleeds and one patient had an upper gastrointestinal hemorrhage. Five patients were changed to warfarin anticoagulation: the patient with upper gastrointestinal hemorrhage and four older patients because of physician preference, all after uncomplicated aspirin therapy. There were no mechanical valve failures, although one patient required reoperation 9 months later for perivalvular leak. All children have remained in normal sinus or paced rhythm during follow-up. These results show that children with mechanical aortic valves in normal sinus rhythm can be safely treated with aspirin (or aspirin with dipyridamole) with little risk of thromboembolic events, valve thrombosis, or valve failure. Hemorrhagic complications resulting from aspirin are minor and easily treated.

Iodine toxicity in a patient treated by continuous povidone-iodine mediastinal irrigation.

Continuous povidone-iodine irrigation is frequently used to treat mediastinitis after median sternotomy and has been considered safe and effective. We describe a 34-month-old patient with mediastinitis after median sternotomy who was treated with continuous povidone-iodine irrigation and who absorbed toxic quantities of iodine (total serum iodine, 9,375 micrograms/dl; normal range, 4.5 to 9.0 micrograms/dl). An unexplained metabolic acidosis developed, along with changes in mental status, and the patient died. This experience and a thorough review of the literature lead us to believe that continuous povidone-iodine irrigation of the mediastinum is contraindicated.

Effect of inhalation injury on lung water accumulation.

Fourteen thermally injured patients with severe inhalation injury were sequentially studied with the thermal-green dye double indicator dilution technique of extravascular lung water (EVLW) measurement. Eight females and six males (average age, 49 years, and average thermal burn, 37% body surface) were studied for 2-31 days postinjury. All were burned in a closed space, had facial burns, soot in their sputum, and a mean carboxyhemoglobin level of 30%. Nine patients died, six of sepsis, one each of acute renal failure, hepatorenal syndrome, and anoxic brain damage. Mean EVLW on admission was 7.0 +/- 2.9 ml/kg and remained normal in the five survivors and in the patients dying of acute renal failure and anoxic brain damage. Six patients had increases in EVLW, caused by altered pulmonary capillary permeability in five and by elevation of hydrostatic pressures in one patient (hepatorenal death). Of the five patients with permeability edema, one appeared to result from a direct early effect of inhalation injury resulting in an EVLW of 13.3 ml/kg on admission. The other four patients had EVLW increases after the onset of sepsis, resulting in a mean EVLW of 23.2 +/0- 7.2 ml/kg at death (p less than 0.01). Seventy-one per cent of all patients developed pneumonia, which appears to have caused an EVLW increase in one patient; the other EVLW increases were caused by systemic sepsis. In our present study of 14 patients with definite severe inhalation injury only one had an early increase in EVLW directly related to the inhalation injury, an early effect on capillary permeability presumably caused by direct chemical toxicity of inhaled gases. The remaining four cases of permeability edema occurred 4-24 days postinjury and resulted from burn wound or pulmonary sepsis. We thus conclude that increases in EVLW after thermal and inhalational injury are primarily caused by systemic or pulmonary sepsis, and have a delayed onset. Early increases in EVLW may be a result of the chemical toxicity of inhaled gases but are very uncommon, moderate in degree, and are seen only with the severest cases of inhalation injury.

Crystalloid versus colloid for fluid resuscitation of hypovolemic patients.

The choice of the initial asanguinous fluid--either crystalloid or colloid--used for the resuscitation of the hypovolemic patient remains controversial. Colloid supporters argue for the careful preservation of the plasma colloid osmotic pressure (PCOP) to protect the lung from pulmonary edema. A careful analysis of the Starling microvascular forces operative at the pulmonary capillary makes such an effect unlikely. In fact, the lung is relatively immune to hemodilution and any decrease in PCOP is roughly one fourth as important as increases in hydrostatic pressure in causing increased fluid exchange. A critical review of the experimental and clinical studies comparing crystalloid versus colloid resuscitation essentially shows no physiologic difference in the two solutions. Using the thermal-green dye technique of extra-vascular lung water (EVLW) measurement in twenty crystalloid resuscitated trauma (n = 10) and burn (n = 10) patients, we have specifically evaluated the pulmonary effects of profound depression of PCOP and a negative PCOP - PAWP gradient (a shorthand form of the Starling equation argued to predict the presence of pulmonary edema if + 4 mm Hg or less). Average resuscitative fluid volumes during the first two hospital days were: 31.8 litres of crystalloid and no colloid for each burn patient; and 18.5 liters of crystalloid, 21 units of blood and 1 liter of colloid (as fresh frozen plasma) for each trauma patient. EVLW remained in the normal range of 7.0 +/- 1.0 ml/kg during the first five hospital days for all patients despite profound decrease in PCOP (less than 15 mm Hg) and a low or negative PCOP - PAWP gradient. Crystalloid resuscitation clearly is not harmful to the lung and it is equally as effective as colloid resuscitation. Crystalloid is markedly less expensive than colloid and, given the greater cost of colloid without evident benefit, one wonders how their further use can be justified.

Determinants of pulmonary interstitial fluid accumulation after trauma.

We have sequentially measured the daily extravascular lung water (EVLW) changes in 16 severely traumatized patients to better define the principal etiologic factors causing post-traumatic interstitial fluid accumulation and subsequent respiratory failure. We found that severe hemorrhagic shock (mean initial BP = 40 mm Hg), massive transfusion (12.7 liters of blood), and crystalloid resuscitation with resulting hemodilution of plasma colloid osmotic pressure (PCOP) (PCOP less than or equal to 15 mmHg) do not cause EVLW accumulation. Post-traumatic elevations in EVLW were seen after lung contusion (average EVLW = 15.3 +/- 2.5 ml/kg), sepsis (average EVLW = 17.1 +/- 2.9 ml/kg) and cardiac failure (EVLW = 15.3 +/- 0.3 ml/kg). Severe hemorrhagic shock, massive transfusion, and crystalloid resuscitation with resulting hemodilution of plasma colloid oncotic pressure do not cause EVLW accumulation. Post-traumatic elevations in EVLW are seen after lung contusion, sepsis, and cardiac failure. We conclude that after trauma elevations in capillary hydrostatic pressure and capillary permeability alterations resulting from lung contusion or sepsis are the primary determinants of interstitial fluid accumulation.

Elevated pulmonary lymph flow and protein content during status epilepticus in sheep.

The pathophysiology of postictal pulmonary edema was investigated by inducing seizures with bicuculline in nine paralyzed, halothane-anesthetized sheep and measuring of pulmonary lymphatic flow, pulmonary arterial and left atrial pressures, and lymph and plasma albumin concentration. Pulmonary microvascular pressure and transcapillary albumin conductance were calculated. Seizures transiently (less than 15 min) elevated microvascular pressure in all animals; lymph flow increased greater than twofold in response to the increased hydrostatic driving force. However, the elevation in lymph flow, with a stable lymph-to-plasma protein ratio and doubled transcapillary albumin conductance, persisted for the duration of the experiment, more than 3 h after microvascular pressure returned to base line. These changes were neurally mediated because they were blocked by cervical spinal cord transection in four additional animals.