Limited access left thoracotomy for reoperative coronary artery disease: on or off pump.

Between 1971 and 1988 left thoracotomy was performed on pump for selected reoperations. Since 1993, 92 patients were operated on with a limited approach and an increased number of cases were done off pump (70 patients). The purpose of this paper is to describe the transition of our operative techniques from on pump to off pump for reoperative coronary patients. From 1995 to 1999, 22 patients (Group 1) were operated on pump and 70 patients (Group II) off pump; 86 of 92 (93.5%) had reoperations. The demographic data were similar in these two groups regarding age, gender, ejection fraction, and total number of grafts performed. In this study 92 patients had a crude mortality of 4.3%. Limited access thoracotomy provides safer reoperation than previously (1971-1988) with an improved on or off pump (4.5% vs. 4.3%) mortality, compared to the on pump mortality of 10% between 1971-1988. Off-pump operations are performed with increasing frequency and with the same risk and less postoperative complications.

Coronary artery bypass grafting without cardiopulmonary bypass--an attractive alternative in high risk patients.

OBJECTIVE: This study compares preoperative risk factors, estimated, observed, and risk adjusted mortality, and postoperative complications in patients undergoing coronary artery bypass grafting. Patients were divided in two groups depending on operative method: Group A patients had coronary artery bypass grafting using cardiopulmonary bypass. In group B cardiopulmonary bypass was not utilized. Patients operated on between January 1 1995 and August 31 1996 were compared. Group A consisted of 1829 patients and Group B 172. METHODS: Patients were selected to undergo coronary artery bypass grafting without the use of cardiopulmonary bypass either because the surgeon felt that there were contraindications to--or no need for the heart-lung machine. The decision to avoid the use of cardiopulmonary bypass was taken pre-operatively by the individual surgeon. Median sternotomy, formal left thoracotomy or left anterior small thoracotomy were used. The data was collected and validated by the hospital's professional data collectors. Data-analysis was performed using the NY-state database. RESULTS: Previous heart surgery and extensively calcified ascending aorta were significantly more common in Group B as was estimated and observed mortality. This resulted in identical risk-adjusted mortality of 2.8%. When reoperations were reviewed separately risk adjusted mortality was lower in Group B (2.1 versus 3.1%) but this difference was not statistically significant. Cardiovascular-and other-complications were higher in group A patients. In reoperative patients this difference was significant (P = 0.05). The need for postoperative mechanical assistance was also reduced (Group A: 14.9% versus Group B: 1.3% P = 0.01). CONCLUSION: We conclude that coronary artery bypass surgery can be done safely in selected patients without cardiopulmonary bypass. Mortality is unchanged and complications are less frequent. Cost and hospital utilization are decreased. The greatest benefit is observed in reoperations.

Pulmonary resection combined with cardiac operations.

Surgical management of patients with concomitant critical cardiac disease and resectable lung lesions is controversial. During a 7-year period (1982 to 1988), 21 patients underwent combined cardiac and pulmonary operations. Patients had cardiac symptoms only; the lung lesions were found on preoperative chest roentgenograms. The pathological diagnosis was established in only 2 of the patients before operation. All underwent concurrent pulmonary resection during cardiac operations requiring extracorporeal circulation. The pulmonary operations included 17 wedge resections and four lobectomies. The final diagnoses in 8 patients with stage I non-small cell lung cancer included epidermoid carcinoma (4), adenocarcinoma (3), and bronchoalveolar carcinoma (1). Postoperatively, 1 patient required a permanent pacemaker and 1 patient died. The actuarial survival at 5 years for all patients who underwent combined procedures was 95%. The 5-year survival for the 8 patients with lung cancer was 88% compared with 100% for those with benign pulmonary pathology (p = 0.172). This experience suggests that combining pulmonary resection with cardiac operations is safe and offers a favorable prognosis to a select group of patients.

Improved cardiovascular hemodynamics with atrioventricular sequential pacing compared with ventricular demand pacing.

To determine the advantages of atrioventricular (AV) sequential pacing over ventricular demand pacing, paired cardiovascular hemodynamic studies were performed in each pacing mode at a constant heart rate. The paired studies included determination of ejection fraction (EF) by echocardiography and gated blood pool radionuclide scanning, and of cardiac output (CO) by the indicator-dilution method. There was no significant difference in EF with either pacing mode. Determined by echocardiography, EF with AV sequential pacing was 57% compared with 56% with ventricular demand pacing; by the gated blood pool method, EF with AV sequential pacing was 58% compared with 57% in the ventricular mode. Significant improvement with AV sequential pacing was seen in CO (4.75 L/min from 3.75 L/min; p less than 0.01); stroke volume (58 ml from 48 ml; p less than 0.02); arteriovenous oxygen content difference (4.9 vol% from 5.6 vol%; p less than 0.01); total peripheral resistance (1,724 dynes sec cm-5 from 2,025 dynes sec cm-5; p less than 0.01); and cardiac contractility, as reflected by mixing time (6.9 seconds from 8.0 seconds; p less than 0.02). No significant changes were noted in mean arterial or atrial pressure or in systemic oxygen consumption. In a second group of 6 patients, similar paired studies were done in AV sequential pacing modes before and after therapeutic reduction of total peripheral resistance. A significant increase in CO (43%) was observed following reduction in total peripheral resistance. We conclude that AV sequential pacing improves CO more effectively than ventricular demand pacing. Cardiac output can be further enhanced in patients with congestive heart failure by pretreatment with agents to reduce total peripheral resistance.

Influence of length of aortic occlusion with cold potassium cardioplegia on early and late mortality in cardiac valve replacement.

This study determines if prolonged aortic crossclamp time (ACC) with the use of cold potassium cardioplegia during elective cardiac valve replacement contributed to the risk of operative mortality in 225 patients. In Group I (143 patients), the ACC was less than 120 minutes (mean 86) and in Group II (82 patients), it was greater than 120 minutes (mean 146). The preoperative variables showed that Group II contained more severely ill patients who were undergoing more complex operations than in Group I. The operative mortality rate was 7% in Group I and 10% in Group II (p = not significant). Postoperative inotropic support was required in 13% of Group I and 30% of Group II patients (p less than 0.005). Operative mortality in patients in New York Heart Association (NYHA) functional class I and II was 0 and in patients in classes III and IV it was 13% (p less than 0.00008). Five percent of patients in NYHA classes I and II and 32% in classes III and IV required inotropic support (p less than 0.000005). The actuarial survival at 60 months was 88 +/- 3% for Group I and 77 +/- 7% for Group II (NS). For the NYHA class I and II patients, however, it was significantly better (98 +/- 2%) than class III and IV patients (75 +/- 5%) (p less than 0.0001). Analysis by logistic equation revealed that the NYHA functional classes III and IV were significant incremental risk factors for probability of in-hospital mortality (p less than 0.0001) but not the ACC time (p greater than 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Tubular hypoplasia of the descending thoracic aorta. Surgical treatment with a PTFE bypass graft under moderate total body hypothermia.

An 8 1/2-year-old child presenting with hypertension was noted to have tubular hypoplasia of the descending thoracic aorta without collateral circulation on angiography. Surgical management consisted of bypassing the hypoplastic segment (10 cm) using a 10 mm PTFE graft under total body hypothermia to minimize spinal complications. The patient had an uneventful recovery with normalization of blood pressures postoperatively.

Aorta-pulmonary artery shunts with expanded polytetrafluoroethylene (PTFE) tube.

Ten patients underwent an aortapulmonary artery shunt with a polytetrafluoroethylene (PTFE) tube between December, 1976, and October, 1977. Five of them were less than 1 month old. The diameter of the PTFE tube was 5 mm in 9 patients and 4 mm in 1 patient. Seven patients survived the operation. One of them had a clotted shunt, which was reoperated on successfully. Three patients died in the postoperative period, and all had a patent shunt. Overall patency was 90% (9/10). Congestive heart failure refractory to medical treatment developed in 1 patient with a patent Blalock-Taussig and PTFE shunt. In our institution, the Blalock-Taussig shunt is the procedure of choice. The PTFE shunt is used when the anatomy of a patient is unsuitable for a Blalock-Taussig shunt. A tube diameter of 5 mm is optimal for infants when further growth is considered, even if digitalization is necessary to control congestive heart failure.

Sinus venosus atrial septal defect associated with partial anomalous pulmonary venous drainage: surgical repair.

This report descrbies a new technique for the repair of sinus venosus atrial septal defect associated with partial anomalous pulmonary venous drainage. A right atrial wall flap is used both to deflect the anaomalous venous blood into the left atrium and to close the atrial septal defect. Then an atrioplasty is performed. This method does not employ any foreign materials, avoids injury to the sinoatrial node and internodal tracts, and minimizes the risk of obstruction of the ostia of the anomalous pulmonary veins and superior vena cava.