Transventricular aortic cannulation for repair of aortic dissection.

We have used transventricular aortic cannulation as arterial inflow from the heart-lung machine in seven consecutive operations done in 1 year for acute aortic dissection. Satisfactory cardiopulmonary bypass was achieved in all patients.

Minimally invasive axillary-coronary artery bypass.

BACKGROUND: Some patients with proximal obstructive lesions of the left anterior descending coronary artery who are suitable for minimally invasive coronary bypass surgery do not have an available left internal mammary artery because it has already been used for a graft, is diseased or has been damaged. The ascending aorta is not accessible for proximal graft anastomosis from a small anterolateral thoracotomy used to expose the coronary artery. The aim of this report is to show that the axillary artery is suitable for the proximal anastomosis in minimally invasive coronary bypass operations. METHODS: Ten patients had minimally invasive axillary-coronary artery bypass to the anterior descending coronary artery. Cardiopulmonary bypass was not used. The saphenous vein was used in nine and the radial artery in one. RESULTS: Satisfactory grafts were achieved in all patients without mortality or major complications. CONCLUSION: Grafts from the axillary artery can be used successfully for minimally invasive bypass to the anterior descending coronary artery.

Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax.

BACKGROUND: Chylothorax is a challenging clinical problem. Untreated, it carries a high mortality and morbidity. Traditional surgical management for cases refractory to conservative treatment is thoracic duct ligation through a right open thoracotomy. METHODS: We describe 4 patients treated successfully by video-assisted thoracic surgery, using ports and no thoracotomy, and precise ligation and division of the thoracic duct just above the diaphragm. A pericardial window was made in the patient with chylopericardium, as in the patient with end-stage renal disease. Pleurodesis was used in the patient with esophageal carcinoma and the patient with jugular and subclavian vein thrombosis. RESULTS: There were 2 women aged 18 and 42 years and 2 men, aged 61 and 65 years. No procedure-related mortality or morbidity occurred. In patients 1, 2, 3, and 4, the postoperative duration of drainage was 5, 7, 7, and 5 days, respectively (mean duration, 6 days) and the hospital stay, 5, 9, 10, and 5 days, respectively (mean stay, 7 days). There was no recurrence of chylothorax or chylopericardium during follow-up (range, 2 to 24 months; mean follow-up, 9 months). One patient died of esophageal carcinoma 4 months after operation. CONCLUSIONS: Video-assisted thoracic surgery without a thoracotomy is an effective way of treating chylothorax and carries minimal morbidity.

Thoracoscopic mammary artery mobilization in redo minimally invasive coronary bypass operations.

BACKGROUND: It has been stated that thoracoscopic internal thoracic artery (ITA) mobilization is not recommended in the redo minimally invasive direct coronary artery bypass (MIDCAB) situation, presumably because adhesions from the previous coronary artery bypass grafting operation may preclude a thoracoscopic approach. However, there are advantages to thoracoscopic ITA mobilization in MIDCAB that could also be realized in the redo situation. METHODS: In 200 MIDCAB procedures over the last 3 and a half years, 11 patients, ages 49-83 (mean 69), were identified as having undergone an attempted ITA mobilization in a redo situation. RESULTS: Thoracoscopic ITA mobilization was successful in 9 out of 11 patients (81%). One patient had complete pleural symphysis precluding this approach, and 1 patient had poor mammary flow after harvest and this conduit was not used. Both failures were in female octogenarians. CONCLUSIONS: To realize the advantages of a thoracoscopic ITA mobilization MIDCAB, both right and left thoracoscopic ITA mobilization can safely be performed in the redo situation. Thoracic adhesions precluding a thoracoscopic approach were encountered in only 1 of 11 redo coronary artery bypass grafting patients.

Minimally invasive direct coronary artery bypass using H graft for pleural symphysis.

In November 1995, video-assisted minimally invasive direct coronary artery bypass procedure, which is defined as a combination of the thoracoscopic internal mammary artery (IMA) harvest and direct coronary bypass grafting, was introduced for patients who need minimally invasive direct coronary artery bypass (MIDCAB) using IMA. In the thoracoscopic IMA harvest, the pleural adhesions or symphysis present an obstacle. We present a case where a redo patient who had complete pleural symphysis of left chest cavity precluded the thoracoscopic IMA harvest, and MIDCAB with the H graft procedure was performed.

Minimally invasive direct coronary artery bypass for redo patients.

BACKGROUND: The minimally invasive direct coronary artery bypass (MIDCAB) procedure, using a small anterolateral thoracotomy without cardiopulmonary bypass, has been recommended for high-risk patients because it is less traumatic than conventional coronary artery bypass grafting. For redo patients who have patent grafts and pericardial adhesions, the MIDCAB may be preferable to the conventional operation because manipulation of the graft and dissection of adhesions may be minimized. METHODS: Since November 1995, 120 patients underwent the MIDCAB procedure in our institution. Among these patients, there were 25 redo cases (20.8%). We reviewed these redo cases and studied their surgical results (mortality, morbidity, hospital stay, operation time, and postoperative inotropic support). To clarify the usefulness of this procedure, we compared the results of redo operations with those of the first-time operations. RESULTS: For redo MIDCAB, there was one operative death (4%) because of intestinal infarction. The mean hospital stay was 4.3 days and the number of patients who needed postoperative positive inotropic agents was 3 (12%). There was no significant differences between redo and first-time operation patients in mortality, morbidity, hospital stay, operation time, and postoperative inotropic support. CONCLUSIONS: Results of the MIDCAB procedure for redo patients were comparable to those for primary MIDCAB operations.

Surgical results of video-assisted minimally invasive direct coronary artery bypass.

BACKGROUND: A video-assisted minimally invasive direct coronary artery bypass procedure is defined as a combination of video thoracoscopic internal mammary artery harvest and direct coronary bypass grafting through a minithoracotomy without cardiopulmonary bypass. We reviewed our experience with this procedure and examined its efficacy. METHODS: Since November 1995, 110 patients have undergone a minimally invasive direct coronary artery bypass procedure in our institution. Seventy (64%) of them underwent a video-assisted minimally invasive operation (group 1). As a control group (group 2), we reviewed the results in 37 patients who underwent conventional single or double coronary artery bypass grafting using an internal mammary artery graft between 1993 and 1995 and could have been candidates for minimally invasive direct coronary artery bypass grafting. RESULTS: There were two hospital deaths (2.9%) in group 1 and one hospital death (2.7%) in group 2. There were no significant differences in mortality or morbidity between the two groups. The number of patients who needed postoperative positive inotropic agents was significantly greater in group 2, and this group also had a significantly longer mean postoperative intubation time and mean hospital stay than group 1. CONCLUSIONS: The surgical results of video-assisted direct coronary artery bypass procedures were better than those of conventional coronary artery bypass grafting in this review. A long-term follow-up for graft patency is needed.

Early results of thoracoscopic internal mammary artery harvest using an ultrasonic scalpel.

OBJECTIVE: We developed a thoracoscopic internal mammary artery harvest technique using an ultrasonic scalpel, the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH). This is the first report of 9 month follow-up using this technique. METHODS: The Harmonic Scalpel is activated ultrasonically by vibrating at 55000 Hz. Compared with electrocautery, lower heat (<100 degrees C) and less smoke are generated. Thoracoscopic harvest using the Harmonic Scalpel with a hook blade was performed for 48 internal mammary arteries (42 left, six right) in 46 patients. Four (8.7%) of them were redo cases. The left internal mammary to left anterior descending artery and the right internal mammary to right coronary artery anastomoses were accomplished on the beating heart. Two left internal mammary arteries were sequentially, anastomosed to diagonal branches. Graft flow velocity was evaluated with pulsatile wave color Doppler test on the second or third postoperative day and repeated 3 and 6 months later. RESULTS: The mean harvest time was 65 min (range 35-95 min) for the left internal mammary artery and 37 min (range 25-45 min) for the right internal mammary artery. One left internal mammary artery was lost due to intimal dissection. The Harmonic Scalpel-related morbidity was transient left phrenic palsy in one case and mild heat injury at the skin incision in the majority of cases. One Patient (2.2%) expired due to ischemic bowel on the second postoperative day. At a mean of 9 months follow-up, 45 alive patients have been free of angina. Doppler studies revealed diastolic augmentation of the graft flow velocity in 22 left and two right internal mammary arteries on the second or third postoperative day and 23 left and five right internal mammary arteries 3 and 6 months after operation. CONCLUSIONS: Thoracoscopic internal mammary artery harvest is feasible and facilitated by the use of the Harmonic Scalpel. Early results of this technique are encouraging.

Thoracoscopic internal mammary artery harvest for MICABG using the Harmonic Scalpel.

BACKGROUND: Thoracoscopic internal mammary artery (IMA) harvest is technically demanding, particularly on the left side. We have devised a Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) technique to facilitate this procedure, and describe our clinical experience here. METHODS: The Harmonic Scalpel functions with ultrasonic energy, producing less smoke and lower heat than regular electrocautery. A total of 27 (22 left and 5 right) pedicles of the IMA in 23 patients were harvested from the upper margin of the first rib or higher to the lower margin of the fifth rib thoracoscopically using the Harmonic Scalpel with a hook blade. RESULTS: In each case, the IMA harvest was completed thoracoscopically with only the Harmonic Scalpel, decreasing instrument transfers. Each vascular branch was coagulated without charring and was transected with excellent hemostasis. Smokeless views were provided. In the first 17 harvests, Doppler studies 3 months after the procedures demonstrated patent IMAs to the coronary circulation. CONCLUSIONS: The Harmonic Scalpel facilitates thoracoscopic IMA harvest and is expected to minimize hyperthermic damage of the IMA.

Concomitant cardiac and pulmonary operation: the role of cardiopulmonary bypass.

To assess the safety and efficacy of concomitant pulmonary resection and cardiac operation requiring cardiopulmonary bypass, the records of 19 patients were reviewed. Eighteen patients (94.7%) presented with cardiac symptoms and were found to have pulmonary pathology of indeterminate etiology. Pulmonary resections were performed through a median sternotomy in all but 1 patient, who underwent posterolateral thoracotomy and right middle lobectomy after repositioning because dense adhesions prevented adequate dissection through the initial incision. A total of 24 resections were performed. Sixteen (66.7%) were performed on cardiopulmonary bypass. Six wedge resections (25.0%) were performed before bypass. Two lobectomies (8.3%) were performed after infusion of protamine sulfate. Nine patients (47.4%) had benign pathology, 7 (36.8%) had primary carcinoma, and 3 (15.8%) had metastatic disease. Bleeding complications occurred in 15.8% of patients (3/19). There was 1 perioperative death (5.3%), which was due to adult respiratory distress syndrome after intraoperative hemorrhage followed lobectomy for bullous disease. Another patient required lateral extension of the sternotomy during an episode of exsanguinating intraparenchymal pulmonary hemorrhage, which resulted in lobectomy, as well as costochondral and sternal osteomyelitis. A third patient required exploration for bleeding at the staple line. Postoperative complications occurred in 7 patients (36.8%) and were predominantly respiratory (5/7, 71.4%) (p = 0.006). The median postoperative hospitalization was 15 days. Although comparison of patients who underwent pulmonary resection during bypass with those who had resection either before heparinization or after protamine infusion showed no significant difference with respect to age, incidence of malignancy, operation performed, complications, postoperative hospitalization, or survival, this was probably due to the small number of patients in the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty-year follow-up of saphenous vein aortocoronary artery bypass grafting.

The clinical records of our first 100 patients to undergo saphenous vein aortocoronary bypass grafting were reviewed. The procedures were performed between March 19, 1970, and March 30, 1972. The patient population included 84 men, and the mean age was 51.4 years. There were 12 patients with single-vessel disease, 36 with double-vessel disease, and 52 with triple-vessel disease, for an average of 2.4 involved vessels per patient. Forty-eight patients were judged to have diffuse atherosclerotic disease. Twelve patients had left main coronary artery stenoses. Each patient received an average of 1.8 saphenous vein grafts. Thirty-six patients underwent repeat coronary artery bypass grafting after an average of 132.8 months and received an average of 3.5 grafts. This resulted in cumulative reoperative rates of 5%, 14%, 27%, and 36% at 5, 10, 15, and 20 years, respectively. The 5-, 10-, 15-, and 20-year survival rates were 89.8%, 68.4%, 53.1%, and 40.8%, respectively. Survival was not significantly related to the cause of death, cardiac-related causes being predominant. There were no significant relationships between the length of survival and sex, the number of grafts received, or the presence of left main stenosis. Survival was inversely related to age at initial operation (p = 0.046) as well as initial left ventricular end-diastolic pressure (p = 0.033). Survival positively correlated with the occurrence of triple-vessel disease (p = 0.031) and the presence of diffuse disease (p = 0.0077).(ABSTRACT TRUNCATED AT 250 WORDS)

Sternotomy infection: poor prediction by acute phase response and delayed hypersensitivity.

Two hundred twenty-one consecutive adult cardiac surgical patients were examined prospectively for nutritional protein state, acute phase protein response, and delayed hypersensitivity reaction in an attempt to identify patients at high risk for the development of sternal wound infection, which occurred in 6 patients (2.7%). There was no significant correlation between preoperative nutritional protein concentrations (retinol-binding protein, prealbumin, and transferrin) and acute phase protein levels (C-reactive protein, alpha 1-acid glycoprotein, and complements B and C3), nor a statistically significant relationship between nutritional state or acute phase protein response and the development of sternal infection. Preoperative complement C3 levels were elevated, however, in 80.0% of those in whom sternal infections developed compared with 30.6% of those with well-healed wounds. Similarly, postoperative concentrations of alpha 1-acid glycoprotein were elevated in 80.0% of those in whom sternal infections developed compared with 28.6% of those with well-healed wounds. There was no correlation between delayed hypersensitivity and the risk of sternal infection, nor between preoperative nutritional protein and acute phase protein values. Seventy-three percent of patients were anergic on postoperative day 2. Stepwise logistic regression showed that age, body weight, preoperative intensive care unit stay, repeat median sternotomy, internal mammary artery grafting, postoperative hemorrhage, and postoperative cardiac arrest correlated with the development of sternal infection, whereas transfusion requirement, reexploration for bleeding, and the operation performed did not. We conclude that routine delayed hypersensitivity testing is of no value in predicting high-risk cardiac surgical patients when the anergy battery is placed on the preoperative day. Although statistically insignificant, possibly due to the small number of patients in whom sternal infection developed in this study (type II error), a larger study might find preoperative complement C3 and post-operative alpha 1-acid glycoprotein levels to be predictive of patients at risk for the development of sternal wound infection. The final logistic model for the predicted risk 2%) of sternal wound infection is: PREDSWC = exp(EQ)/1 + exp(EQ) where EQ = (0.38 x age) + (0.24 x weight) + (5.42 x preop ICU) + (4.39 x redo) + (7.14 x IMA) + (4.49 x hemorrhage) + (8.81 x arrest) - 62.72, and where preop ICU, redo, hemorrhage, and arrest are defined as yes (1) or no (0), IMA-is defined as 0, 1, or 2, age is in years, and weight is in kilograms.

Presentation of undiagnosed pheochromocytoma during coronary artery bypass surgery.

Hypertension and tachyarrhythmias arising during an operative procedure are rarely caused by an unsuspected pheochromocytoma. However, when this tumor becomes clinically manifest under general anesthesia during a procedure for an unrelated condition, the mortality is high. An unusual case of a patient who developed episodes of catastrophic hypertension and tachyarrhythmias while undergoing a coronary artery bypass procedure is described. The subject of undiagnosed pheochromocytoma becoming clinically manifest under general anesthesia is discussed with a pertinent review of the literature.