Echocardiographically guided removal of an intracardiac foreign body.

BACKGROUND: Foreign bodies lodged in the heart can easily be missed during surgical repair of penetrating cardiac wounds. SUMMARY: We report the use of intraoperative echocardiography to identify and accurately locate a small cardiac foreign body. Our patient had a fragment of a drill bit lodged in his left atrium as the result of an industrial accident. He initially underwent emergency median sternotomy because of acute tamponade, but the foreign body was not found, and he subsequently required a second procedure to remove it. Intraoperative transesophageal and epicardial echocardiography during the second procedure confirmed the position of the metallic fragment, excluded the possibility of other lodged foreign particles, and ruled out other types of penetrating injury to the heart. CONCLUSIONS: Intraoperative echocardiography should be standard procedure in the removal of intracardiac foreign bodies.

Intraoperative Doppler color flow mapping for decision-making in valve repair for mitral regurgitation. Technique and results in 100 patients.

Mitral valve repair provides substantial advantages over mitral valve replacement in patients with severe mitral regurgitation. However, because of the possibility of persistent regurgitation, an intraoperative technique is needed to provide an immediate and accurate assessment of the adequacy of the repair before closure of the chest. One hundred patients with pure mitral regurgitation were studied with intraoperative epicardial Doppler color flow mapping immediately before and after valve repair. Intraoperative assessment of the severity of mitral regurgitation showed good agreement with preoperative left ventriculography and with standard precordial Doppler echocardiography before and after surgery. Postrepair intraoperative Doppler studies showed satisfactory surgical results in 92 patients. Postrepair intraoperative Doppler studies in the remaining eight patients demonstrated unsatisfactory results: persistent significant regurgitation in four, systolic anterior motion of the mitral valve with dynamic left ventricular outflow tract obstruction in three, and a persistent flail leaflet in one. In six of the eight patients, further surgery was performed during the same thoracotomy. In two patients, the intraoperative postrepair Doppler findings of persistent regurgitation were confirmed on precordial Doppler studies within 5 days, and mitral reoperation was required. Intraoperative epicardial Doppler color flow mapping provided a "safety net" that ensured a successful outcome in all 100 patients by providing the surgeon with a direct means to assess the success of the operation and the need for further surgery.

Partial anomalous pulmonary venous drainage. A novel approach to repair.

Isolated partial anomalous pulmonary venous drainage with an intact atrial septum is a rare finding. The authors describe their experience with three patients (ages 9, 37, and 54 years), with partial anomalous pulmonary venous connection to the superior vena cava, right atrium, and inferior vena cava, who underwent extracardiac conduit repair of this anomaly. In all three patients, a synthetic Gortex graft was used for reconstruction of the venous pathways to the left atrium. The follow-up period ranged from 10 to 82 months (mean, 42 months). All three patients were evaluated with intravenous digital angiography, transesophageal echocardiography, or both at 10, 33, and 82 months postoperatively. Patency of the grafts with no evidence of obstruction and excellent pulmonary venous flow was shown. This surgical technique is an excellent option for correction of this anomaly, and intravenous digital subtraction angiography is a useful diagnostic tool during the postoperative period to evaluate patency of the repair.

Ebstein's anomaly: natural and unnatural history.

Clinical features and natural history were analyzed in 30 patients with Ebstein's anomaly (mean age 26 years, range 1.5-58 years, 53% females). The main presenting symptoms were dyspnea and fatigue (83%). At presentation, there were six patients (20%) in New York Heart Association Functional Class (NYHAFC) I, nine (30%) in NYHA-FC II, and 15 (50%) in NYHA-FC III or IV; 12 patients (40%) were cyanotic. Common auscultatory findings were widely split second heart sound in 21 (70%), third heart sound in 14 (47%), fourth heart sound in 16 (53%), and a systolic murmur in 22 (73%). Right bundle branch block was present in 21 (70%), documented supraventricular tachycardia in seven (23%), and Wolff-Parkinson-White syndrome in three (10%). Catheterization was performed in 93% without complications. Fourteen patients were treated surgically (12 [86%] in NYHA-FC III or IV, 10 [71%] with associated anomalies); tricuspid valve replacement was performed in eight, atrial septal defect repair in two, accessory pathway ablation in two, right atrial plication in one, and automatic cardioverter defibrillator implantation in one. Surgical treatment improved 10 patients from NYHA-FC III or IV to NYHA-FC I or II. Death occurred in nine patients (five treated surgically and four medically); four of these deaths were sudden. In the eight patients who had tricuspid valve replacement, there were one operative and two late deaths. The authors conclude that surgical therapy with tricuspid valve replacement improves the clinical status of patients who are severely ill. Risk of sudden death remains an important problem in patients with Ebstein's anomaly regardless of severity of the disease and mode of treatment.

Long-term function of the morphologic right ventricle in adult patients with corrected transposition of the great arteries.

Because of the concern about the ability of the morphologic right ventricle (MRV) to function over a long term as a systemic ventricle, adult patients with congenitally corrected transposition of the great arteries (CCTGA) were evaluated to determine the long-term function of the MRV. Morphologic right ventricular function was assessed by functional clinical classification and angiographic ejection fraction in 18 adult patients with congenitally corrected transposition of the great arteries. These patients had a mean age of 30.2 +/- 14.5 years (range 10 to 67 years). All but one had hemodynamically significant lesions, the most common being left atrioventricular valve regurgitation (11 patients), ventricular septal defect (seven patients), atrial septal defect (four patients), and pulmonic stenosis (three patients). The mean MRV ejection fraction at presentation was 55% +/- 11.5% (range 24% to 74%). Twelve of the 18 patients (67%) were followed clinically, with a mean follow-up time of 9.9 +/- 7.1 years (range 1 to 22 years). Eight were reassessed angiographically, with a mean MRV ejection fraction of 51.3% +/- 10.7% (range 30% to 67%). The other four were followed up clinically and evaluated by two-dimensional echocardiography, with normal MRV function in two patients. Eight of 12 patients (67%) were in functional class I at follow-up, one was in functional class II, one was in functional class III, and two had died. Our data suggest that the morphologic right ventricle can function appropriately over a long term in adult patients with congenitally corrected transposition of the great arteries.(ABSTRACT TRUNCATED AT 250 WORDS)

Marfan's syndrome: natural history and long-term follow-up of cardiovascular involvement.

A retrospective analysis was undertaken to define the natural history and long-term follow-up of a group of patients with Marfan's syndrome. Eighty-four patients were diagnosed between January 1959 and June 1987 as having Marfan's syndrome; 68% were male; their ages ranged from 2 to 67 years (mean 26.6). Sixteen patients constituted the early surgical group (those who underwent surgery before 1979; mean age 36.1 years). Nineteen patients constituted the late surgical group (surgery in 1979 or later; mean age 33.3 years). The nonsurgical group comprised 49 patients (mean age 19.3 years). Fifty-seven percent of the patients had a diastolic murmur and 38% had cardiomegaly at presentation. Fifty-seven percent underwent cardiac catheterization, which revealed aortic root dilation (85%), aortic regurgitation (73%), aortic dissection (33%) and mitral regurgitation (36%). Thirteen of the 19 patients in the late surgical group received a composite graft repair of the ascending aorta as compared with only 2 of the 16 in the early surgical group. Follow-up information was obtained on 81 (96%) of 84 patients; the follow-up time was 2 to 332 months (mean 99). Thirty-one of the 81 patients died at age 3 to 63 years (mean age 35 years); 87% of the known causes of death were related to the cardiovascular system. Sixty-one percent of deaths were the result of aortic dissection or rupture or sudden cardiac death. Of the 50 survivors, 98%, including all patients in the late surgical group, were in functional class I or II. Overall survival at 5, 10 and 15 years after operation was 78.4%, 57.1% and 49.5%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary isolated aortic valve replacement. Early and late results.

A total of 1689 consecutive patients underwent isolated aortic valve replacement at the Cleveland Clinic Foundation from 1972 through 1986. There were 57 (3.4%) in-hospital deaths. Multivariate analysis identified advanced age (p = 0.0014), preoperative blood urea nitrogen level greater than 25 mg/100 ml (p = 0.008), New York Heart Association function class (p = 0.015), and preoperative atrial fibrillation (p = 0.04) as independent variables associated with increased in-hospital mortality and the use of cardioplegia for myocardial protection (p = 0.006) as a factor decreasing mortality. Follow-up documented survival rates of 85% and 66% and event-free survival rates of 71% and 43% at 5 and 10 postoperative years, respectively. Advanced age, moderate or severe impairment of left ventricular function, coronary artery disease, and preoperative blood urea nitrogen level greater than 25 mg/100 ml were associated with decreased late survival and event-free survival (all p less than 0.05). Patients with bioprostheses had better survival (p = 0.003) and event-free survival (p = 0.0007) rates than patients with mechanical valves. Patients with bioprostheses had superior results only if not receiving warfarin, and they experienced more reoperations and endocarditis; those with mechanical prostheses had more strokes, myocardial infarctions, bleeding complications, and thromboembolic events. Analysis of patients grouped according to age at operation showed that bioprostheses were associated with improved survival and event-free survival for patients 40 years older or older. Younger patients experienced more reoperations and episodes of endocarditis, and older patients more thromboembolic complications. We conclude that 10-year results after isolated aortic valve replacement are influenced by both patient-related and management-related variables, and the impact of these factors is different for patients of different ages.

Applicability of mitral valvuloplasty techniques in a North American population.

Records of 520 patients who underwent mitral valve operations were reviewed to determine the pathophysiology, etiology, anatomy of the valve lesion and use of valvuloplasty techniques. Pure mitral regurgitation, present in 269 patients (52%), was the most common lesion while rheumatic valvulitis, seen in 286 patients (55%), was the most common etiology. Degenerative lesions were found in 168 patients, 33% of the total and 63% of the pure mitral regurgitation group. Two-hundred seventy patients (52%) were treated with valvuloplasty techniques. The incidence of reconstructive procedures was determined for each of the various patient subsets. Overall hospital mortality was 5.6% in the series: 8.4% for mitral replacement compared with 3% for mitral valvuloplasty (p = 0.007). Among patients undergoing primary isolated mitral procedures, hospital mortality for replacement was 7.5% compared with 1.4% for valvuloplasty (p = 0.018). Mitral valvuloplasty seems to provide a therapeutic alternative applicable to the spectrum of mitral valve pathology seen in a North American population.

Does bilateral internal mammary artery grafting increase surgical risk?

The risk of bilateral internal mammary artery grafting was studied in three groups of patients who were computer matched for recognized risk factors: year of operation, age, gender, extent of coronary artery disease, left ventricular function, completeness of myocardial revascularization, and history of congestive heart failure. The patient groups differed in the fact that they received veins only, one internal mammary artery graft, or two internal mammary artery grafts. The operative mortality rates for these three groups were 1.8%, 0.3%, and 0.9%, respectively (no significant difference). Analysis of perioperative morbidity demonstrated no significant differences except for a slight increase in transfusion requirements in the group receiving two internal mammary artery grafts (p = 0.04). None of the patients with only vein grafts had wound complications. One patient in the group with one internal mammary artery graft had a wound complication (0.03%). Eight patients receiving two internal mammary artery grafts had wound complications (2.4%) (p = 0.002). The prevalence of wound complications in patients with diabetes mellitus was 5.7% and in those without diabetes mellitus, 0.3% (p = 0.01). The prevalence of wound complications in patients less than 60 years of age was 0.2%, in patients in their 60s, 1.6%, and in patients older than 70, 3.1% (p = 0.01). Multivariate logistic regression analysis identified diabetes mellitus and age and not bilateral internal mammary artery grafting as risk factors for wound complications. We conclude that bilateral internal mammary artery grafting does not increase surgical mortality and increases surgical morbidity by a slight increase in the mean transfusion requirement.

Aortic valve replacement combined with myocardial revascularization. Late results and determinants of risk for 471 in-hospital survivors.

Among 500 patients consecutively undergoing primary aortic valve replacement combined with coronary bypass grafting from 1967 to 1981, there were 29 (5.8%) perioperative deaths. Follow-up of the late survivors ranged from 43 to 181 months (mean 85 months); actuarial survival rates were 88%, 77%, and 52% and event-free survival rates were 80%, 65%, and 32% at 2, 5, and 10 postoperative years. Cox proportional hazard analyses were used to identify determinants of late risk. Patient-related variables associated with decreased late survival rates included advanced age, cardiothoracic ratio 50% or greater, and preoperative New York Heart Association class III or IV symptoms. Moderate or severe impairment of left ventricular function as determined by angiography and advanced age were variables that decreased late event-free survival rates. Patients with bioprostheses had better survival rates (p less than 0.001) and event-free survival rates (p = 0.012) than did patients with mechanical valves. Analyses of subgroups according to the type of valve and postoperative anticoagulant management showed that both survival and event-free survival rates were decreased for patients with mechanical valves who were not taking warfarin and were enhanced for patients with bioprostheses who were not taking warfarin.

Intraoperative Doppler echocardiography in hypertrophic cardiomyopathy: correlations with the obstructive gradient.

Although significant pressure gradients can be recorded across the left ventricular outflow tract in patients with hypertrophic cardiomyopathy, controversy exists regarding the presence or absence of true obstruction. Ten patients with hypertrophic cardiomyopathy were studied at the time of septal myectomy. A sterile continuous wave Doppler transducer was placed on the ascending aorta and directed toward the left ventricular outflow tract to measure velocity simultaneously with invasive gradient measured using solid-state hub transducers by direct puncture of the left ventricle and aorta. Simultaneous Doppler velocity and invasive gradient measurements (n = 33) were made at rest, before and after myectomy and during interventions with isoproterenol, volume loading and phenylephrine. High velocity flow with a characteristic contour was recorded in patients with a significant gradient. Using the modified Bernoulli equation (gradient = 4 X velocity), a good correlation was found between the Doppler-derived gradient and the peak instantaneous gradient measured invasively (r = 0.93, y = 0.89X + 12, p = 0.0001). Changes in gradient and velocity due to interventions also correlated well (r = 0.96, y = 0.91X - 3, p = 0.0001). Continuous wave Doppler echocardiography can accurately estimate the outflow tract gradient. The magnitude, timing and contour of these high velocity flow signals support the hypothesis that true obstruction is present in patients with hypertrophic cardiomyopathy who have a significant gradient.

Ventricular septal defect in the adult: natural and unnatural history.

From 1951 to 1981 we evaluated 79 adult patients with ventricular septal defect with no other associated cardiac malformations. There were 42 men and 37 women ranging in age from 18 to 59 years (mean 34 years). We divided our patients into 67 patients treated medically and 12 surgically. Follow-up was obtained on 78 of 79 patients (99%). All patients were followed up for 1 month to 25 years (mean 9 years). Their ages at follow-up ranged from 24 to 70 years (mean 42 years). Nonsurgically treated patients who were New York Heart Association functional class I before treatment had a significantly better survival rate than had those who were functional class II to IV (p less than 0.001). Nonsurgically treated patients with cardiomegaly had a significantly poorer survival experience than had those without pretreatment cardiomegaly (p less than 0.001). Medical patients also had significantly poorer survival rates if the mean pulmonary artery systolic pressure was greater than 50 mm Hg (p less than 0.001). The 10-year survival rate for all patients was 76%. In general, adult patients with ventricular septal defect treated medically remained clinically stable over a long follow-up period, but survival was significantly influenced by pretreatment functional class, pulmonary artery systolic pressure, and cardiomegaly.

Fifteen hundred coronary reoperations. Results and determinants of early and late survival.

Fifteen hundred consecutive patients undergoing a first reoperation for coronary revascularization were reviewed to determine early and late results and predictors of survival. Patients were subdivided into cohorts on the basis of the year of reoperation: Group A (1967 to 1978, 436 patients); Group B (1979 to 1981, 439 patients); and Group C (1982 to 1984, 625 patients). Overall operative mortality was 3.4% (51 deaths): 4.6%, 2.3%, and 3.4% for Groups A, B, and C, respectively. Group C had significantly more women (p = 0.01) and patients with triple-vessel disease, left main coronary artery stenosis (greater than or equal to 50%), abnormal left ventricular function, age greater than or equal to 70 years, and graft failure as a surgical indication (all p less than 0.001). The mean interval between operations increased from 50 months for Group A to 84 months for Group C. At reoperation, Group C patients received more grafts, more internal mammary artery grafts, and had a higher prevalence of complete revascularization (all p less than 0.001). Univariate and multivariate analyses identified left main stenosis (p less than 0.0001), Class III or IV symptoms (p = 0.0002), advanced age (p = 0.0006), Group A (p = 0.02), and incomplete revascularization (p = 0.004) as predictors of increased in-hospital mortality. Follow-up of in-hospital survivors (mean interval 54 months, range 13 to 171 months) documented a 5 year survival rate of 90% and a 10 year survival rate of 75%. Multivariate testing identified advanced age (p less than 0.0001), hypertension (p less than 0.0001), and abnormal left ventricular function (p less than 0.0001) as predictors of decreased late survival.

Reoperations for valve surgery: perioperative mortality and determinants of risk for 1,000 patients, 1958-1984.

One thousand consecutive cardiac reoperations for valve surgery in 897 patients were reviewed to determine in-hospital mortality and indicators of risk. Subgroups based on the number of previous cardiac procedures and the valve or valves replaced or repaired at reoperation (aortic valve, mitral valve, tricuspid valve, or multiple valves and mortality [deaths/number of procedures (% mortality)]) for those subgroups are as follows: (Table: see text) Predictors of increased risk for a first aortic valve reoperation were advanced age (p = .0002), endocarditis (p = .0018), female sex (p = .014), impaired left ventricular function (p = .039), and number of coronary vessels obstructed by 70% or more (p = .055). For a first mitral valve reoperation, the predictors were advanced age (p less than .0001), preoperative shock or cardiac arrest (p = .01), previous aortic or tricuspid valve operations (p = .02), type of mitral valve procedure (risk for repair of periprosthetic leak was greater than mitral valve replacement which was greater than mitral valve-conserving operation [p = .05]), and impaired left ventricular function (p = .059). For a first multiple valve reoperation, the predictors were diabetes (p = .04) and ascites (p = .02), whereas patients undergoing mitral valve replacement and tricuspid valve operations were at decreased risk (p = .01). Comparison of second reoperations with first reoperations indicates risk increases for multiple operations (p = .01) but not for aortic or mitral valve procedures. Rereplacement of a prosthesis (p = .007), coronary bypass grafting at reoperation (p = .006), and advanced age (p = .06) increased the risk for second reoperations. Age is the most consistent predictor of risk for patients undergoing valve reoperations.

Digital subtraction angiography in the diagnosis of vascular rings.

Digital subtraction angiography was performed in six patients suspected of having a vascular ring. There were four males and two females. Two patients were less than 6 months of age, two were between 14 and 20 months, and two were ages 4 and 53 years. Four of the six patients had abnormal esophagrams. Five patients underwent peripheral intravenous digital subtraction angiography and a sixth patient underwent digital subtraction angiography via arterial catheterization. In two patients (ages 20 months and 4 years), the presence of a vascular ring was excluded by demonstrating an anatomically normal arch with an anomalous right subclavian artery. In three patients, a right aortic arch was present. Two of these patients had mirror image branching and a left ligamentum arteriosum. The third patient had an aberrant left subclavian artery and a left ligamentum. One patient had an anomalous right subclavian artery and a systemic collateral vessel arising from the aorta, supplying a confluence of vessels in the right lung hilum. In all patients, anatomic definition was accurate with the intravenous injection and there were no complications. In the patient who underwent intra-arterial injection, the dose of contrast was reduced 50% from the dose usually administered. Digital subtraction angiography appears to be a good adjunctive diagnostic method in patients in whom the presence of a vascular ring needs to be confirmed angiographically and obviates the need for arterial catheterization.

Predictors of reoperation after myocardial revascularization.

The first 1,000 patients undergoing primary isolated myocardial revascularization each year from 1971 to 1978 were analyzed to define the incidence of reoperation and to elucidate the determinants of reoperation and reoperation-free survival. Six hundred sixty-six patients (9.7%) underwent reoperation in a mean of 6.9 +/- 3.2 years. Cumulative percent reoperation was 2.7% at 5 years, 11.4% at 10 years, and 17.3% at 12 years. The annual incidence of reoperation was 1.1% at 5 years and increased to 3.9% at 12 years. Twenty-five patient descriptors were analyzed for predictors of reoperation. Young age was found to be the most important predictor of potential for reoperation. Other risk factors in descending order of significance were absence of an internal mammary artery graft, incomplete revascularization, New York Heart Association Functional Class III/IV, and single or double vessel disease. Absence of an internal mammary artery graft was an important predictor for all age groups. In the multivariate analyses for risk factors for reoperation-free survival, absence of an internal mammary artery graft was the most important predictor. Other factors of major significance were smoking, incomplete revascularization, and moderate/severe left ventricular impairment. Internal mammary artery grafting neutralizes hypertension, serum cholesterol level higher than 300 mg/dl, and smoking as risk factors for reoperation-free survival.