The DiMarco-Jurado pleuropericardioplasties: complete closure of the pericardial space with advancement/rotation flaps after adult primary cardiac operations.

This article describes three new techniques for completely closing the pericardial space. They entail the creation of three flaps of living, vascularized tissue: two pericardial and one pleural. Utilizing advancement and rotational plastic surgical principles, complete closure can be performed without tension or the use of any pericardial substitutes. These flaps create great laxity and tissue redundancy during closure, greatly reducing any possibility of graft compromise or impairment of myocardial diastolic function. There are three types of closure described, types I and Ia, and type II, creating great versatility in closing the pericardial space (and adaptability to the surgeon's preferences). These flaps are able to create pericardial tissue redundancy (and therefore laxity upon closure) in both the transverse and longitudinal directions, and are therefore suitable to any cardiac procedure. The advantages of these techniques in creating a tension-free complete closure include the possibility of a safer reoperation if needed. The DiMarco-Jurado pleuropericardioplasties as described are quick and easy methods to completely close the pericardial space without tension and may be utilized after all adult (and possibly pediatric) primary cardiac procedures.

Management of postcardiotomy hypertension by microcomputer-controlled administration of sodium nitroprusside.

Manual administration of sodium nitroprusside in patients who have undergone cardiac operations can be associated with wide swings in mean systemic arterial pressure. Moreover, it is necessary for constant attention to be paid in order to minimize these potentially catastrophic arterial pressure changes. A microcomputer-based controller was constructed in the belief that it might improve the accuracy of systemic arterial pressure control as well as relieve the clinical staff of a time-consuming task. Comparison was made of the effectiveness of manual control versus computer control of sodium nitroprusside infusion in two groups of patients with similar clinical characteristics. In the manual control group the mean systemic arterial pressure could be maintained within 5 mm Hg of the target pressure only half (52%) of the time. In the computer-controlled group the mean systemic arterial pressure was maintained within 5 mm Hg of the target pressure 94% of the time (p less than 0.005). Thus, computerized control of sodium nitroprusside infusion eliminated the need for an intensive care unit nurse to be "locked into" the task of making frequent adjustments of infusion rate. Of even greater importance, control of mean systemic arterial pressure was more precise.

Right to left intracardiac shunt: a unique presentation of metastatic cardiac disease.

A 54 year old man presented with signs and symptoms of severe hypoxemia. He had a history of a nasopharyngeal epidermoid carcinoma that was thought to have been totally eradicated 2 years earlier. He was found to have a right to left interatrial shunt through a patent foramen ovale due to tricuspid valve obstruction by a solitary cardiac metastasis. No other such reported case of a metastatic cardiac lesion could be found.

Stability of procaine hydrochloride in a buffered cardioplegia formulation.

The stability of procaine hydrochloride in a buffered cardioplegia solution was studied. The formulation of Ringer's injection with added increments of potassium and magnesium plus procaine hydrochloride was buffered to a pH of 7.3-7.6 with tromethamine. Procaine hydrochloride content was measured in triplicate by ultraviolet spectrophotometry at set time intervals and at temperatures of 22, 40, and 61 degrees C. The time required for procaine to degrade to the lower shelf-life limit of 90% of its initial concentration was extrapolated to be approximately two days at room temperature and 11 days under refrigeration. It is recommended that the basic buffered cardioplegia solvent be manufactured separately, and the procaine hydrochloride be added at the time of dispensing to minimize its loss of potency.

Administering cold cardioplegia in patients undergoing coronary artery bypass grafting.

In patients undergoing coronary artery bypass grafting (CABG), use of hypothermic cardioplegia for myocardial protection may not always achieve even cooling in the areas distal to a severely obstructed artery. Employing simultaneous myocardial temperature measurements, we documented "warm" areas in some patients having CABG. We then devised a technique of combined aortic root and intracoronary cardioplegic infusion. This has achieved prompt cooling of the warm areas and has resulted in uniform myocardial temperatures of 5 degrees to 8 degrees C.

Improved detection of adverse cardiovascular trends with the use of a two-variable computer alarm.

Assessment of preload and afterload of patients having undergone cardiac surgery is commonly done by the monitoring of mean arterial and left atrial pressures (MAP, LAP). In this ICU, a central computer has been in use to sample routinely the MAP and LAP every 10 min. This computer has been programmed to activate an alarm sequence if a routinely acquired value of MAP or LAP is found to be outside of preset ("trend") limits. The computer then initiates a repeat mode of sampling of MAP and LAP as 1 min intervals. If three consecutive repeated values of either variable remain outside of the preset limits, then the following occurs: 1) a plot of the trend of MAP and LAP over the preceding 3 h appears on the bedside video monitor, 2) a bedside light and audible chime are activated, and 3) the bedside keyboard is locked out to other functions until the alarm is reset. A study showed that this system can detect adverse trends appropriately, averaging only 1-2 false alarms/patient per 8-h shift.

A simple left heart assist device for use after intracardiac surgery: development, deployment and clinical experience.

A simple left heart assist device (LHAD) has been developed and employed in nineteen patients with severe left ventricular dysfunction who could not be weaned from cardiopulmonary bypass following intracardiac surgery. It has been used when all other means of weaning, including maximum pharmacologic therapy and intra-aortic balloon counterpulsation (IABC), had failed. The device utilizes specially designed and constructed obturated cannulae in the left atrium and the ascending aorta, and an extracorporeal roller pump to partially bypass the left ventricle. With improved cardiac performance, the patient may be separated from the device without need for thoracic reentry. Of the nineteen patients having LHAD support (2-500 hours), thirteen were eventually weaned from the device and seven were discharged from the hospital. Five patients remain alive and well (18 to 50 months postoperatively).

Reduction of unexpected, life-threatening events in postoperative cardiac surgical patients; the role of computerized surveillance.

With increasing use of computerized surveillance (CS) in critical care, a key question is whether it favorably influences clinical outcome. Knowing that two intensive care unit beds would soon have CS capability, we embarked on an uninterrupted prospective study in which the incidence of sudden, unexpected life-threatening events (SULTE) was compared in post-open heart surgery patients whose subsystem performances were evaluated by conventional methods (CM) as opposed to those who would be followed by CS involving automatic acquisition and generation of 30 cardio-respiratory variables. We evaluated 211 patients, 91 with CM and 120 by CS. Since CS availability was limited, sicker patients were given priority for the two CS beds. Despite the obvious bias in favor of CM, there was a statistically significant reduction (P less than 0.001) in the incidence of SULTE in those patients followed by CS (1 of 120 patients: 0.8%; no SULTE-related deaths) in comparison to the CM patients (11 of 91 patients: 12%; two SULTE-related deaths.) The data suggest that computerized surveillance can play a role in reducing morbidity and possibly mortality in postoperative cardiac surgical patients.

Left heart assist device: early clinical experiences with management of postperfusion low cardiac output.

Low cardiac output is a continuing cause of mortality after intracardiac operation in patients coming to surgery with advanced myocardial dysfunction. A simple method using a left heart assist device (LHAD) after open heart surgery to manage low cardiac output resistant to all adjuvant therapy is described. Except for the special cannulas, all equipment necessary for the LHAD is available in any unit performing open-heart surgery. Fifteen patients who could not be separated from conventional cardiopulmonary bypass underwent postoperative support with the LHAD (up to 501 hours). Ten patients were weaned from the device and 6 were dismissed from the hospital. Four patients remain alive, the longest period after operation being 24 months. A major asset of the LHAD is that thoracic reentry is not required at termination of LHAD support, since their design permits the cannulas to remain permanently in situ. This is thought to be an important concept, since critically ill patients requiring support are precisely those in whom added risk would be imposed by a second operation.

Temporary mechanical support of left ventricular failure following open heart surgery.

Patients coming to open heart surgery with advanced cardiac dysfunction may require mechanical cardiac support to avoid life-threatening low cardiac output in the postoperative period. 15 patients who could not be withdrawn from cardiopulmonary bypass because of low cardiac output were supported with a left heart bypass system (left atrium to ascending aorta). Ten were ultimately separated from the device, 6 were dismissed from the hospital and 4 remain well (the longest 2.6 years postoperative). A major asset of the device is that thoracic reentry is not required when support is discontinued.

Role of the Hancock "stabilized glutaraldehyde process" bioprosthesis in the management of mitral valve disease.

The low mortality of isolated mitral valve (MV) replacement permits attention to be focused on those valve-related factors which affect the quality of life after operation. Comparison of a number of MV prostheses indicates that all perform satisfactorily from the hemodynamic standpoint. An asset of the "stabilized glutaraldehyde process" (SGP) Hancock bioprosthesis (H-B) is the significantly lower incidence of thromboembolism encountered in patients who have not been permanently anticoagulated. While additional time is required before meaningful durability comparisons can be made, the absence of valve failure and the low incidence of tissue dysfunction in H-B over 6 1/2 years is encouraging. Although the ideal device for replacing the MV is not yet available, the Hancock SGP bioprostheses represent the best compromise of available choices.

Postcardiotomy low cardiac output clinical experience with a left heart assist device.

Fifteen patients with advanced heart disease who could not be withdrawn from cardiopulmonary bypass (CPBP) because of low cardiac output were supported with a left heart assist device (LHAD). The system (left atrium to ascending aorta bypass of left ventricle) was not employed until all other measures had failed to allow separation from CPBP, including intraaortic balloon counterpulsation whenever possible. In this experience no attempt was made to totally bypass the left ventricle (LV). Rather, LHAD flow rate was adjusted so that the combined output of the LHAD and depressed LV achieved satisfactory levels of systemic blood flow at acceptable LV filling pressures. With improved cardiac performance patients were separated from the LHAD without need for thoracic reentry. Of the 15 patients having LHAD support (longest 21 days), 10 could be separated from the device and six were dismissed from the hospital. Four remain well, the longest 1.6 years postoperatively. Patients requiring 3 days or less of circulatory assistance had a more favorable prognosis than those needing more extended periods of support.

Circulatory support with a left-heart assist device after intracardiac operation: design concepts and management techniques.

A simple left-heart assist device was developed to reduce left ventricular preload while simultaneously increasing total systemic blood flow. It consists of special cannulas connected to a simple extracorporeal tubing loop and roller pump, designed to permit bypass of as much as 5 liters of blood per minute from left atrium to ascending aorta. Employed in 15 patients with advanced heart disease who were in low cardiac output following repair, the system was proven effective. An asset of the device is the ability to subsequently separate the patient from the device without need to reenter the thorax or abdomen.

Use of a left heart assist device after intracardiac surgery: technique and clinical experience.

A left heart assist device (LHAD) has been employed in 14 patients. All had advanced heart disease and were in low cardiac output after repair, such that they could not be separated from cardiopulmonary bypass despite prolonged support and adjuvant therapy, including drugs, pacing, and use of intraaortic balloon counterpulsation whenever possible. Apart from special cannulas, the equipment necessary for the LHAD is widely available. An asset of the system (left atrial-ascending aorta bypass of the left ventricle) is that it may be terminated without reentering the thorax to remove the cannulas. This is accomplished with precisely fitting obturators that obliterate the cannula lumens and allow the tubes to be permanently implanted. This concept is believed important since critically ill patients requiring support are precisely those in whom added risk would be imposed by a second operation. Of the 14 patients who have had intraoperative and postoperative support (up to 6.8 days), 9 were weaned from the device and 6 were dismissed from the hospital. Four patients remain alive and are improved, the longest at 22 months since operation. The favorable performance of the LHAD suggests that it may prove useful either when intraaortic balloon counterpulsation cannot be successfully deployed or when it has failed to achieve hemodynamic stability.

The use of vein allografts as sidearms for intraaortic balloon insertion.

Femoral artery cannulation for intraaortic balloon counterpulsation may be attended by difficulties due to changes in the vessel wall and the inherent stiffness of Dacron grafts. A substitute technique utilizing venous allografts is described. The advantages are enumerated and are related to allograft pliability. Fifty-nine such procedures have been done without related complications.