Risks of cerebrovascular events related to open heart surgery.

Prevention of perioperative cerebrovascular injury in patients undergoing open heart surgery is a serious task for the surgeon, especially as age and severity of atherosclerotic disease increases. The most significant predisposing factors have been identified as existing carotid arterial disease or prior stroke, heavy calcification of the aorta, renal dysfunction, advanced age, and diabetes mellitus. We have studied a series of 600 open heart patients from 1992 to 1995 from the incidence of peri-operative stroke and mortality, evaluating 16 risk factors: heavy calcification of the ascending aorta, asymptomatic carotid disease, insulin-dependent diabetes mellitus, prior CVA, left ventricular function (ejection fraction of 20% or less), age greater than 70, renal dysfunction, transmural myocardial infarction, fluid balance index greater than 2500 ccs, smoking, type of procedure, emergency procedure, non-insulin-dependent diabetes mellitus, cardiopulmonary bypass time, gender, and hypertension Stroke occurred in 8 patients (1.3%), one of whom die postoperatively. Full or near-full recovery was experienced by 5 patients; 2 patients remained partially dysfunctional at the end of the study period. The operative mortality was 2.0% (12 patients); 10 deaths occurred in hospital and 2 following discharge within 30 days postoperatively. The risk of stroke was 15 times greater in patients over age 70; 16 times greater in older males (> or = 70 years); 5 times greater in patients with prior stroke or existing (asymptomatic) carotid artery disease; 8 times greater in patients with renal dysfunction; 4 times greater with a positive fluid balance index; and twice greater when cardiopulmonary bypass exceeded 110 minutes. Four of the stroke patients had diabetes mellitus. Two of 9 patients with heavy calcification of the aortic arch suffered cerebrovascular injury. Six or more of the risk factors studied were present in 81 patients; all 8 stroke patients (9.9%) came from this subgroup. The study suggests the importance of pre-operative evaluation of cerebrovascular atherosclerotic disease and the minimal manipulation ("minimal touch" technique) of a calcific aortic arch.

Significance of asymptomatic biliary tract disease in heart transplant recipients.

Biliary disease in conjunction with heart transplantation was encountered in 13 of 33 patients: in the past history (three patients), at pretransplant evaluation (nine patients), and appearing de novo after transplantation (one patient). Four patients with asymptomatic cholelithiasis underwent transplantation: biliary complications requiring emergency and/or urgent surgery occurred in all, with two deaths. Potentially complicating factors included (1) untoward effects of steroids on tissue healing and infection and (2) interaction between liver dysfunction and/or external bile loss and cyclosporine metabolism. Therapeutic lessons learned from this experience involve (1) selection of monoclonal antibodies over methylprednisolone for rejection control, (2) return of drained bile to the gastrointestinal tract, and (3) careful cyclosporine level and dosage monitoring. Five candidates with asymptomatic cholelithiasis underwent elective pretransplant biliary surgery; despite their compromised heart function, all patients had an uncomplicated postoperative course. We conclude that asymptomatic biliary disease is frequent in transplant candidates, can lead to serious morbidity and/or mortality after transplantation, and ideally can and should be treated before transplantation.

Infective endocarditis: diagnosis, treatment, and mortality, as related to surgical timing and infectious organism.

To evaluate the timing of surgical treatment in infective endocarditis and to determine the relationship between the risk of mortality and the species of infectious organism, we reviewed a consecutive series of 65 cases involving patients with infective endocarditis who had been treated over a 17-year period. The patients included 41 males and 24 females, who ranged in age from 6 to 85 years (mean, 39.3 years). Forty-five had native valve endocarditis, 14 had prosthetic valve endocarditis, and six had endocarditis associated with congenital heart defects. Fifty-two patients underwent valve replacement, which was associated with an overall operative mortality of 19%. Those who underwent valve replacement during the early active stage (first 3 weeks) of infection had a higher mortality rate than those who had surgery either during the late active stage (second 3 weeks) of infection or after 6 weeks of antibiotic therapy. S. aureus and Pseudomonas organisms were responsible for the most deaths. On the basis of this study, we recommend that, when cardiovascular function permits, patients who are hemodynamically stable and free of emboli should receive 4 to 6 weeks of antibiotic therapy before undergoing surgical treatment. In contrast, patients with high-risk organisms are more likely to survive if subjected to early surgical intervention.

The use of the gastroepiploic artery for coronary artery bypass graft: another alternative.

The right gastroepiploic artery was successfully used for coronary artery bypass graft (CABG) in two patients whose saphenous veins were unavailable for grafting. One internal mammary artery was used in each patient. Because the gastroepiploic is an arterial pedicle, it is expected to have a good long-term patency rate and should be considered as an alternative conduit.

Malignant clinical behavior of cardiac myxomas and "myxoid imitators".

The clinical experience with cardiac myxomas and "myxoid imitators" at the Humana Heart Institute International is reviewed and contrasted with a comprehensive review of the world literature. Twenty-two patients with primary cardiac tumors have been treated at our institution. Three (13.6%) of them had myxoid imitators, and 19 had classic myxomas. One of the 19 patients with a classic myxoma had recurrence on two occasions (recurrence rate, 5.3%). The cases of 57 patients from the world literature are reviewed. Recurrence and/or metastases (including formation of mycotic aneurysm) occurred in approximately 50% of these patients. The overall mortality in these patients was 47%. This review provides documentation of the malignant clinical behavior of cardiac myxomas and myxoid imitators. Neither local recurrence nor regrowth of the tumor in a new location, whether intracardiac or extracardiac, can be predicted from the microscopic appearance of the primary tumor. Resection of the myxoma with a wide margin is the recommended surgical procedure but does not ensure a cure. Therefore, long-term follow-up is mandatory.

Vein graft arteriovenous fistula for long-term venous access in a heart transplant recipient lacking superficial veins: a case report.

Construction of a (radial artery) saphenous vein graft arteriovenous fistula for blood sampling after heart transplantation is presented as a solution to the problem of a patient with poor or sclerosed superficial arm veins. Satisfactory experience with one patient over a 12.5 month follow-up is presented.

Circular myotomy as an aid to resection and end-to-end anastomosis of the esophagus.

Segments ranging from 40 to 70% of the thoracic esophagus were resected in 80 mongrel dogs. End-to-end anastomosis was effected after circular myotomy either proximal or distal, or both proximal and distal, to the anastomosis. Among dogs undergoing resection of 60% of the esophagus, distal myotomy enabled 6 of 8 animals to survive, and combined proximal and distal myotomy permitted 8 of 10 to survive. Cineesophagography was performed in a majority of the 50 surviving animals and showed no appreciable delay of peristalsis at the myotomy sites. When these sites were examined at postmortem examination up to 13 months after operation, 1 dog showed a small diverticulum but none showed dilatation or stricture. It is concluded that circular myotomy holds real promise as a means of extending the clinical application of esophageal resection with end-to-end anastomosis.