Surgical treatment of multiple intracardiac and pulmonary artery tumor implants embolic from uterine intravascular leiomyomatosis

Intravenous uterine leiomyomatosis is the invasion of the para-uterine veins by bundles of benign uterine muscle. These muscle bundles can grow and extend directly to pelvic organs or embolize to the right cardiac chambers or pulmonary artery. We report a patient who presented with two large mobile atrial masses that were seen on echocardiography. She was treated by excision of a 18cm mass from the right atrium, two masses from the right ventricle and a huge mass from the pulmonary artery. The tricuspid valve that was rendered insufficient, was repaired by the creation of PTFE neo chordae. Two weeks later a massively enlarged uterus, ovaries, a paracolic and three intraluminal masses in the inferior vena cava were removed. The patient recovered well. One year after surgery she was asymptomatic and no masses are seen in her echocardiogram. The tricuspid valve was competent. Patients presenting with cardiac tumors from intravenous uterine leiomyomatosis must undergo aggressive surgical management to achieve a cure. We recommend a two stage (thoracic and abdominal) approach.

Repair of posterior coronary lacerations.

Posterior lacerations of the coronary arteries that occur during arteriotomy should be repaired if significant. We describe a modification of the standard technique to repair posterior coronary artery lacerations. This technique avoids distortion and narrowing of the coronary artery.

Intraluminal milrinone for dilation of the radial artery graft.

There is renewed interest in the use of the radial artery as a conduit for coronary artery bypass surgery. The radial artery is, however, a very muscular artery, prone to vasospasm. Milrinone, a potent vasodilator, has demonstrated vasodilatory properties superior to those of papaverine. In this report, we describe our technique of radial artery harvesting and the adjunctive use of intraluminal milrinone as a vasodilator in the preparation of this conduit for coronary artery bypass grafting. We have used these techniques in 25 patients who have undergone coronary artery bypass grafting using the radial artery. No hand ischemic complications have been observed in this group. Intraluminal milrinone appears to dilate and relax the radial artery, rendering this large conduit spasm free and very easy to use. We recommend the skeletonization technique for radial artery harvesting and the use of intraluminal milrinone as a radial artery vasodilator in routine myocardial revascularization.

Left ventricular volume reduction and reconstruction in ischemic cardiomyopathy.

BACKGROUND: Ischemic cardiomyopathy can be the result of large or small myocardial infarctions or due to myocardial hibernation. Patients with an end-systolic volume index >100 mL¿m2 do not benefit from revascularization alone and require an operation that reduces ventricular volume. Various approaches to reduce ventricular volume have been described. We applied several of these techniques in patients with end-stage ischemic cardiomyopathy. METHODS: Forty eight patients with end-stage ischemic cardiomyopathy (Class III-IV) underwent left ventricular volume reduction operations with coronary revascularization and mitral valve repair or Alfieri valvoplasty. Fourteen patients underwent interpapillary resections, 22 anterior resections, 4 posterior resections, 2 anterior and posterior resections, and 6 patients reduction of left ventricular volume with endocavitary patches. RESULTS: All the techniques used improved left ventricular function. Analysis of mortality revealed that extensive resections (interpapillary, anterior, and posterior resection) had a 43% mortality. However, a limited resection or a ventricular reconstruction with an endocavitary patch had only a 12.5% mortality. When we changed our approach to a more conservative one, mortality was reduced from 26% the first 12 months to 13% in the last 15 months of the study. CONCLUSIONS: Ischemic cardiomyopathy has a poor prognosis if the end-systolic volume index exceeds 100 mL/m2. Various procedures exist to reduce left ventricular volume. Extensive ventricular resections improve ventricular function, but have a high mortality. This led us to use other methods of ventricular volume reduction such as more conservative resections combined with left ventricular reconstructions or ventricular volume reduction with endocavitary patches. Mortality was reduced significantly by this approach. The patients that survived have remained Class I-II in a follow-up that extends up to 30 months. Surgical therapy of Class III-IV ischemic cardiomyopathy is feasible, but aggressive ventricular resections have a high mortality. We advocate a more reconstructive approach with limited or no ventricular resection.

Surgical treatment of aortic dissections: initial experience with the adventitial inversion technique.

BACKGROUND: The adventitial inversion technique obliterates the false lumen and converts a dissected aorta into a conduit with tough adventitia on the inside and outside. Dacron grafts can be anastomosed to the aorta with fine sutures, which hold without tears. METHODS: From August 1995 to March 1997, we treated 6 patients with acute dissecting aneurysms. Three aneurysms were type I (A) involving the entire aorta, two type II (A) involving the ascending aorta, and one type III (B) involving the thoracoabdominal aorta. Circulatory arrest was used in 3 patients, 1 with type I aneurysm (A), 1 type II (A), and 1 type III (B). RESULTS: All Dacron-aorta anastomoses held sutures well and did not bleed intraoperatively or postoperatively. One patient (type II [A]) died of intraoperative low cardiac output. In patients with type I (A) aneurysms, the false lumen was obliterated, but 1 patient required resection of a 6-cm abdominal aortic aneurysm. CONCLUSIONS: The adventitial inversion technique is a safe technique for the treatment of acute dissecting aneurysms, which facilitates operation and solves the problem of intraoperative or postoperative bleeding due to tissue friability.

Coronary artery endarterectomy: a method of myocardial preservation.

The lack of acceptable coronary arteries for grafting often causes the cardiac surgeon considerable problems in treating patients with severe coronary artery disease. By combining the standard approach of coronary bypass surgery with coronary endarterectomy and with retrograde coronary sinus cardioplegia perfusion, we can achieve a longer ischemic period and can flush the debris from the coronary arteries in a retrograde fashion. Using this approach, we managed 72 patients with near inoperable coronary artery disease. One third of these patients required endarterectomy of more than one vessel. A higher than expected number of patients had diabetes mellitus. The left coronary artery system required endarterectomy in almost 60% of patients, much higher than percentages reported in other series of patients. The mortality rate in our patients who underwent the left system endarterectomy was 5.7%. Endarterectomy must be considered an adjunct in the management of high-risk patients with severe coronary artery disease.

Cardiac surgery on Jehova's Witnesses at Instituto Cardiovascular-Hospital Pavia.

Jehovah's Witnesses (J.W.) can undergo successful cardiac operations. We have operated five J.W. patients. Of these patients, two had coronary artery bypass surgery and three had correction of congenital anomalies. These included an atrial septal defect with infundibular pulmonic stenosis, a tetralogy of Fallot and a patient with a ventricular septal defect. Our treatment protocol includes a meticulous surgery, the use of early heparinization to collect all shed blood into the pump oxygenator, observation in the operating room for early exploration if the patient bleeds and administration of iron preparations. Recombinant human erythropoietin, although available and in our treatment protocol, has not been used yet. All patients survived the operation and left the hospital with an excellent hemoglobin and hematocrit. The length of stay varied from 7 to 15 days.

Carotid patch angioplasty: immediate and long-term results.

To determine the benefit of carotid patch angioplasty, a retrospective study of 1000 consecutive carotid endarterectomies was done. Based on the type of carotid endarterectomy closure, patients were divided into four groups: 250 had primary closure, 250 had expanded polytetrafluoroethylene patch, 250 had Dacron patch, and 250 had saphenous vein patch. On the basis of operative technique or type of carotid artery closure, no statistical difference was found in the incidence of postoperative stroke (p greater than 0.25): primary closure 1.6% (4), expanded polytetrafluoroethylene 2.0% (5), Dacron patch 1.6% (4), and saphenous vein patch (0). Postoperative carotid patency was determined by B-mode ultrasonography, and 717 patients were evaluated in follow-up extending to 6 years (mean 37.8 months). Based on the method of carotid endarterectomy closure, no significant difference (p greater than 0.25) was found in the incidence of significant restenosis (greater than 50% diameter reduction): primary closure 4.0% (7), expanded polytetrafluoroethylene 4.0% (6), Dacron 5.4% (9), and saphenous vein 1.0% (2). Significant restenosis was most frequent in habitual smokers (93%, 25/28) and females (78%, 22/28) despite the method of carotid endarterectomy closure. No statistical difference was found in the incidence of late ipsilateral stroke either (p greater than 0.25): primary closure 2.9% (5), expanded polytetrafluoroethylene 2% (3), Dacron 5% (3), and saphenous vein 0%. These results indicate that the incidence of postoperative stroke, regardless of method of arterial closure, was not statistically different. The method of carotid closure did not appear to affect the occurrence of late ipsilateral stroke or restenosis; however, patch angioplasty with saphenous vein appears appropriate in habitual smokers, and likely in patients with small internal carotid arteries.

Left ventricular assistance with the centrifugal pump: management of the patient with stunned myocardium.

Prompt left ventricular assistance by the centrifugal pump enables the survival of many patients with postoperative low cardiac output who cannot be weaned from cardiopulmonary bypass with the aid of balloon counterpulsation and inotropic agents. Successful weaning from the centrifugal pump, however, depends on the careful selection of appropriate candidates as well as the strict control of pump flow, oncotic pressure, coagulopathy, blood pressure, and systemic afterload. The installation of a hemoconcentration device into the pump line helps control hemodilution and maintain adequate oncotic pressure. The management of a patient who was totally dependent upon left ventricular assistance is described.

A flexible system for combined retrograde and antegrade delivery of blood or crystalloid cardioplegic solution.

A flexible but simple cardioplegic delivery system has been designed that offers the advantages of alternating antegrade and retrograde delivery or blood and crystalloid (Plegisol¿ solution) cardioplegia to optimize myocardial preservation. Initial antegrade delivery of crystalloid cardioplegic solution achieves rapid cardiac arrest while subsequent retrograde delivery with blood cardioplegia improves myocardial protection due to uniform distribution of the solution. Occasionally, temporary transferral from blood to crystalloid is indicated to clarify the surgical field. This system is designed to allow the repeated rapid switching from crystalloid to blood cardioplegia or vice versa using the antegrade or retrograde routes.

A technique for spot application of fibrin glue during open heart operations.

Several techniques have been described for preparing and applying fibrin glue to control surgical bleeding. However, these methods tend to be cumbersome, expensive, or messy. Furthermore, commercial kits have not been approved by the Food and Drug Administration because of the potential risk of hepatitis contamination. Therefore, we have devised a modified, simpler technique that enables the precise, pinpoint application of fibrin glue. The risk of hepatitis transmission is substantially reduced by using cryoprecipitate plasma instead of fibrinogen from pooled donors. This technique is especially well suited for anastomoses of small vessels or for sealing suture holes in nonporous grafts.

Generation of chordae tendineae with polytetrafluoroethylene stents. Results of mitral valve chordal replacement in sheep.

Surgical repair of ruptured or elongated chordae tendineae of the mitral valve is one of the most complex reconstructive techniques in cardiac surgery. Various surgical procedures have been described to repair chordal abnormalities of the anterior leaflet of the mitral valve with unpredictable results. Mitral valve replacement is usually recommended in that situation. This report describes a simple repair technique that we have devised. We resected one or two marginal chordae of the anterior leaflet of the mitral valve in 35 sheep and replaced them with a double-armed, pledget-supported, expanded polytetrafluoroethylene suture. The 30 surviving animals were studied hemodynamically and were electively put to death 3, 6, 9, 18, and 24 months after the operation. Mitral insufficiency did not develop in any of the sheep. All specimens had a normal mitral valve without thrombosis. The polytetrafluoroethylene suture remained pliable and was incorporated into the anterior leaflet and papillary muscle. Scanning and transmission electron microscopy showed that the suture was completely covered by a sheath of tissue with a collagen structure remarkably similar to that of a native chorda. Calcification was not detected in the new chordae. This reproducible and safe technique may considerably simplify the difficult repair of chordal abnormalities.

Four-year patency of PTFE grafts after replacement of the superior vena cava and the innominate veins.

We describe a simpler alternative to treating vena cava syndrome with composite spiral vein grafts. Instead, we used 2 polytetrafluoroethylene (PTFE) grafts to replace the resected superior vena cava and innominate veins of a man with a malignant thymoma. Both grafts have remained patent more than 4 years after surgery, and the patient has continued asymptomatic and free of malignancy. Therefore, we recommend using PTFE grafts to replace the great veins of the thorax.