Myocardial revascularization for situs inversus totalis and dextrocardia.

Situs inversus totalis with dextrocardia is rare and presentation with coronary artery disease in the ninth decade of life is even rarer. Here we describe a case where a patient underwent coronary stenting and subsequently coronary bypass surgery for the same.

Plasma and urinary cytokine homeostasis and renal function during cardiac surgery without cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) significantly contributes to the plasma pro-inflammatory cytokine response at cardiac surgery. Complementary plasma and urinary anti-inflammatory cytokine responses have been described. The pro-inflammatory cytokines interleukin 8 (IL-8), tumour necrosis factor alpha (TNF-alpha) and interleukin 1beta (IL-1beta) have lower molecular weights than the anti-inflammatory cytokines interleukin 10 (IL-10), interleukin 1 receptor antagonist (IL-1ra) and TNF soluble receptor 2 (TNFsr2) and thus undergo glomerular filtration more readily. In vitro work suggests that proximal tubular cells are vulnerable to pro-inflammatory cytokine mediated injury. Accordingly, this study investigated the hypothesis that cardiac surgery without CPB would not have significant changes in plasma and urinary cytokines and proximal renal dysfunction. Eight patients undergoing coronary artery bypass grafting (CABG) without CPB were studied. Blood and urine samples were analysed for pro- and anti-inflammatory cytokines. Proximal tubular dysfunction was measured using urinary Nu-acetyl-beta-D-glucosaminidase (NAG)/creatinine and alpha(1)-microglobulin/creatinine ratios. Plasma IL-8, IL-10, IL-1ra and TNFsr2 were significantly elevated compared with baseline. Urinary IL-1ra and TNFsr2 were significantly elevated, as were urinary NAG/creatinine and alpha(1)-microglobulin/creatinine ratios. Two hours following revascularization, urinary IL-1ra correlated with urinary alpha(1)-microglobulin/creatinine ratios (P<0.05). As previously reported in CABG surgery with CPB, we now report that non-CPB cardiac surgery also has significant changes in plasma and urinary cytokine homeostasis and early proximal tubular injury. The correlation between urinary IL-1ra and alpha(1)-microglobulin/creatinine ratios is consistent with earlier suggestions of a mechanistic link between cytokine changes and proximal tubular dysfunction. The relative roles of CPB and non-CPB processes in producing inflammation still require definition.

Repeat heart valve surgery: risk factors for operative mortality.

BACKGROUND: Patients undergoing repeat heart valve operations are a diverse population. We assessed risk factors for operative mortality in patients undergoing a first heart valve reoperation. METHODS: A retrospective review of hospital records was performed for 671 patients who underwent first repeat heart valve operations between 1969 and 1998. Univariable and multivariable analyses were performed. RESULTS: Operative mortality was 8.6%. Mortality fell each decade to 4.8% in the most recent period (adjusted chi(2) for linear trend P <.0005). Mortality increased from 3.0% for reoperation for a failed repair or reoperation at a new valve site to 10.6% for prosthetic valve dysfunction or periprosthetic leak and to 29.4% for endocarditis or valve thrombosis. Concomitant coronary artery bypass grafting was associated with a mortality of 15.4% compared with 8.2% when it was not required. Mortality for aortic valve replacement was 6.4%, mitral valve replacement 7.4%, aortic and mitral valve replacement 11.5%, tricuspid valve replacement 25.6%, periprosthetic leak repair 9.1%, and isolated valve repair 2.2%. Among 336 patients requiring replacement of prosthetic valves, mortality was 26.1% for replacement of a mechanical valve compared with 8.6% for replacement of a tissue valve (P <.0005). Multivariable analyses identified year of reoperation, age, coronary artery bypass grafting, indication, and replacement of a mechanical valve rather than a tissue valve as significant explanatory variables for operative mortality. CONCLUSIONS: Heart valve reoperations can be performed with an acceptable operative mortality. However, we have identified several categories of patients in whom reoperation carries an increased risk.

Mechanical or bioprosthetic valves in the elderly: a 20-year comparison.

BACKGROUND: Our objective was to compare long-term results of mechanical and bioprosthetic valve replacement in patients older than 70 years. METHODS: Patients older than 70 years who had either a St. Jude Medical (SJM) mechanical prosthesis or any bioprosthesis (BP) implanted between January 1977 and December 1997 were identified. Alive patients were interviewed by telephone during a closing interval of 130 days. RESULTS: Complete follow-up was achieved with a total follow-up of 2,264 patient years. A total of 547 patients had 448 aortic valve replacements (199 SJM and 249 BP) and 99 had mitral valve replacements (76 SJM and 23 BP). A further 30 patients had double valve replacement. One hundred ninety of the 577 patients (33%) had coronary artery bypass grafting in addition to the valve replacement. Survival analysis showed no advantage for either mechanical or bioprosthetic valves. There was also no difference in thromboembolic rates, paravalvular leaks, structural dysfunction, and endocarditis rates. However, patients with mechanical valves had a significantly greater risk of major (p < 0.0001) and minor bleeding (p = 0.002) events. CONCLUSIONS: Bioprosthetic valves do not offer a survival advantage over mechanical valves among the elderly. However, anticoagulant-related mortality and morbidity is statistically higher for patients with mechanical valves.

Plasma and urinary cytokine homeostasis and renal dysfunction during cardiac surgery.

BACKGROUND: Cardiac surgery induces changes in plasma cytokines. Proinflammatory cytokines have been associated with a number of renal diseases. The proinflammatory cytokines interleukin 8 (IL-8), tumor necrosis factor alpha (TNFalpha), and interleukin 1beta (IL-1beta) are smaller than the antiinflammatory cytokines interleukin 10 (IL-10), interleukin 1 receptor antagonist (IL-1ra), and TNF soluble receptor 2 (TNFsr2), and thus undergo glomerular filtration more readily. Accordingly, this study investigated the relation between plasma and urinary cytokines and proximal renal dysfunction during cardiac surgery. METHODS: Twenty patients undergoing coronary artery bypass grafting with cardiopulmonary bypass (CPB) were studied. Blood and urine samples were analyzed for proinflammatory and antiinflammatory cytokines. Proximal tubular dysfunction was measured using urinary N-acetyl-beta-d-glucosaminidase (NAG)/creatinine and alpha1-microglobulin/creatinine ratios. RESULTS: Plasma IL-8, IL-10, IL-1ra, and TNFsr2 values were significantly elevated compared with baseline. Urinary IL-1ra and TNFsr2 were significantly elevated. Urinary NAG/creatinine and alpha1-microglobulin/creatinine ratios were also elevated. Plasma TNFalpha at 2 h correlated with urinary NAG/creatinine ratio at 2 and 6 h (P < 0.05) and with urinary IL-1ra at 2 h (P < 0.05). Plasma IL-8 at 2 h correlated with NAG/creatinine at 6 h (P < 0.05). Urinary IL-1ra correlated with urinary NAG/creatinine ratio after cross-clamp release and 2 and 6 h after CPB (P < 0.05). CONCLUSIONS: Cardiac surgery using CPB leads to changes in plasma and urinary cytokine homeostasis that correlate with renal proximal tubular dysfunction. This dysfunction may be related to the renal filtration of proinflammatory mediators. Renal autoprotective mechanisms may involve the intrarenal generation of antiinflammatory cytokines.

Clinical and hemodynamic performance of the Toronto SPV bioprosthesis.

BACKGROUND AND AIM OF THE STUDY: By providing a superior hemodynamic profile, the stentless valve design allows ventricular remodeling and may improve patient survival after aortic valve replacement (AVR). Compared with stent-mounted prostheses, implantation is more complex and requires a longer ischemic time; this may adversely affect surgical risk, especially if patients are elderly or require a concomitant procedure. The mid-term clinical and hemodynamic performance of the Toronto SPV bioprosthesis in a predominantly elderly patient group was analyzed. METHODS: A total of 123 patients (median age 72 years) underwent AVR with the Toronto SPV. Concomitant procedures (mainly coronary artery bypass grafting, CABG), were performed in 60 patients (49%). Clinical details were recorded, with 100% follow up (total 317 patient-years). Hemodynamic evaluation, by serial echocardiography, was performed at four and 18 months after implantation. RESULTS: The early mortality rate was low (0.8%). Mean (+/- SD) actuarial survival at 53 months was 78 +/- 5.9%, with most patients (91%) in NYHA classes I and II. Freedom from valve-related complications were: endocarditis 93.8 +/- 2.3%, thromboembolism 90.3 +/- 3.7% and bleeding 95.8 +/- 1.8%; there were no structural failures. The valve hemodynamic profile was excellent for all sizes: peak gradient 8.8 +/- 4.3 mmHg, effective orifice area 1.9 +/- 0.54 cm2 with significant improvement in left ventricular fractional shortening. CONCLUSION: In this patient population the Toronto SPV was a suitable choice. Advanced age, a requirement for concomitant procedures and increased ischemic times did not adversely affect surgical risk. AVR with the Toronto SPV provided an excellent hemodynamic profile, and improved both left ventricular function and NYHA functional class.

An unusual iatrogenic cause of right coronary air embolism.

A 62-year-old woman undergoing redo mitral valve replacement was noted to have persistent intracardiac air following standard deairing procedures. Transesophageal echocardiography (TEE) identified air bubbles entering the left atrium from the right superior pulmonary vein. Exploration of the pleural cavity revealed a fistula between the pulmonary parenchyma and the right superior pulmonary vein caused by the atriotomy closure suture transfixing the edge of the lung, which was repaired with immediate disappearance of the air emboli. This demonstrates that transesophageal echocardiography is an invaluable aid to ensuring complete deairing after open heart procedures.

Simultaneous transhiatal esophagectomy and coronary artery bypass grafting without cardiopulmonary bypass.

A 69-year-old patient underwent simultaneous transhiatal esophagectomy for carcinoma of the esophagogastric junction and benign spindle cell gastric tumor and coronary artery bypass grafting without cardiopulmonary bypass. A standard technique of transhiatal esophagectomy was used. The long saphenous vein was grafted to the left anterior descending artery and to the distal circumflex artery. The total theatre time was 6.5 h and the total ischemic time was 19 min. The patient made a good recovery and was discharged on day 18. He is enjoying an active lifestyle 6 months post-operatively.

Simultaneous cardiac surgery with pulmonary resection: presentation of series and review of literature.

BACKGROUND: The issue of performing simultaneous pulmonary resection and cardiac surgery in patients with coexisting lung carcinoma and ischaemic heart disease remains controversial. We report our experience and review the literature. METHODS: Thirteen patients (male ten, female three; mean age 65 years) underwent simultaneous cardiac surgery and pulmonary resection. Lung pathology consisted of primary lung carcinoma (n = 10), benign disease (n = 2) and carcinoid (n = 1). Lung resections included pneumonectomy (n = 3), lobectomy (n = 4), segmentectomy (n = 1) and local excision (n = 5). Cardiac procedures consisted of coronary artery bypass grafting (CABG) in 11, aortic valve replacement in one and mitral valve repair with CABG in one patient. In all but one case the lung resection was performed prior to heparinization and cardiopulmonary bypass (CPB). In two patients, with suitable coronary anatomy, myocardial revascularization without CPB was performed to reduce morbidity. RESULTS: There was no hospital mortality. Postoperative blood loss and ventilation requirements were reduced in the patients who were operated on without CPB. Prolonged ventilatory support was required in two cases. All patients with benign pathology are alive. In the lung cancer group there have been five late deaths: disseminated metastatic disease (n = 3), anticoagulant related haemorrhage (n = 1) and broncho-pleural fistula (n = 1). Of the remaining five patients four are alive and disease free 7-23 months post-operatively; one patient has recurrent disease 40 months post-operatively. CONCLUSIONS: Simultaneous pulmonary resection and cardiac surgery is associated with acceptable operative morbidity and mortality. In patients with lung carcinoma long-term survival was determined by tumour stage. The avoidance of CPB may be advantageous by decreasing blood loss and ventilation requirements.

Noise levels in a cardiac surgical intensive care unit: a preliminary study conducted in secret.

Noise in hospitals frequently exceeds recommended levels and has detrimental psychological and physiological effects on patients and staff. The aim of this study was to record the noise levels within the cardiac surgical intensive care unit (CSICU) environment in secret. The device used was a CEL Instruments environmental noise meter concealed in a dummy box featuring temperature and humidity digital displays. It allowed greater than 16 hours recording time at a 1-minute resolution. The 24-hour period was covered by overlapping recordings. The data collected were downloaded onto a personal computer for analysis. The maximum sound level recorded was 100.9 decibel level (dBA), 1 min Lmax (the maximum sound level occurring in a 1-min period). The minimum sound level was 61.3 dBA 1 min Lmax. The continuous background noise was at its lowest at 57.5 dBA 1 min equivalent continuous sound pressure levels (Leq) and at its peak 77.3 dBA 1 min Leq. Noise in the CSICU was above the recommended levels for patients and staff well-being. Future studies will be designed to establish a correlation between sound levels and events.

Recurrence of aortic coarctation following repair by re-implantation of the subclavian artery.

Four patients mean age six months, range 11 days to 2 years, underwent repair of aortic coarctation by the technique of reimplantation of the subclavian artery (Mendonca repair). All developed re-coarctation within six months of an initially successful repair.

Aortic valve replacement with frozen irradiated homografts. An 18-year experience.

Between May 1968 and April 1981, 339 patients underwent isolated aortic valve replacement using frozen irradiated homografts. All the operations were carried out by the same surgeon (EJMW) using the same technique. Thirty-two patients were lost to follow-up at various stages and the long-term results of the remaining 307 patients are reported. Two hundred and thirty-four were males and 73 females. Their ages ranged between 10 and 75 years, with a mean age of 53. The dominant lesion was aortic stenosis in 195 cases (63.5%), aortic regurgitation in 68 (22.1%), and mixed aortic valve disease in 44 (14.3%). Early mortality was 8.8% and late mortality during the 5-18 year follow-up period was 49.6%. Re-operations for homograft failure were carried out in 112 patients (40%), with an early mortality of 25%. The results are compared with those of other major series using antibiotic sterilized homograft valves.

Distal internal mammary artery (IMA) with retrograde flow for coronary artery grafting.

A case in which the right distal internal mammary artery (IMA) was used to graft the posterior descending branch of the right coronary artery is presented. The retrograde blood flow at dissection was 60 ml per minute, no electrocardiographic signs of myocardial ischemia were detected postoperatively. The patient is well and fully active 6 months after surgery.

Late results of mitral valve replacement using unstented antibiotic sterilised aortic homografts.

Three hundred and seventy nine patients who had undergone mitral valve replacement using unstented antibiotic sterilised aortic homografts were followed up for 52 to 138 months (mean 102 months). Patients requiring additional aortic valve replacement were excluded. The commonest cause was rheumatic heart disease (321 patients). There were 37 early deaths (9.8%) and 97 late deaths (28%). The actuarial survival of operative survivors was 83% at three years, 75% at five years, and 55% at nine years. Technical valve failure occurred in six patients (1.6%), infective endocarditis in 19 (5%), and degeneration of the valve in 43 (12.5%). The cumulative probability of freedom from endocarditis was 96% at three years, 94% at five years, and 91% at nine years, while that of freedom from valve degeneration was 97% at five years and 48% at 10 years. There were no early embolic episodes, but late embolism occurred in five patients (1.5%).