Peri-infarct pursestring for repair of subacute cardiac rupture.

A 55-year-old woman presented with cardiac tamponade after an inferior myocardial infarction. At surgical exploration there was an extensive area of hematoma associated with cardiac rupture. Rather than infarctectomy and ventricular repair an alternative approach was taken. The patient was successfully managed by the placement of a peri-infarct pursestring together with a superficial stitch closing the exit point of the cardiac rupture.

Paraplegia as a result of intra-aortic balloon counterpulsation.

A case of paraplegia after a perioperative intra-aortic balloon support is presented. This rare and devastating complication is the twelfth reported in international literature.

The use of cardiopulmonary bypass with profound hypothermia and circulatory arrest during the surgical treatment of giant intracranial aneurysms.

The surgical treatment of giant intracranial aneurysms can be aided by using cardiopulmonary bypass to provide hypotension under hypothermic conditions. Cardiopulmonary techniques need to be modified to deal with the problems that arise during this type of neurosurgery.

Effect of high-dose fentanyl anaesthesia on the metabolic and endocrine response to cardiac surgery.

The effect of high-dose fentanyl anaesthesia (75 micrograms kg-1) on the metabolic and endocrine responses to cardiac surgery was compared with results obtained in similar patients who had received incremental doses of papaveretum. High-dose fentanyl anaesthesia prevented the increases in blood glucose, plasma cortisol and plasma growth hormone concentrations found before cardiopulmonary bypass, but during cardiopulmonary bypass was only effective in decreasing the hyperglycaemia. The continued administration of fentanyl following operation failed to suppress the hormonal and metabolic changes so that the total urinary excretion during the first 5 days after surgery was similar in both groups of patients. High-dose fentanyl anaesthesia was associated with only transient metabolic benefits confined to the period during operation.

Functional significance of coronary arterial stenoses assessed by regional changes in intramyocardial S-T segment voltage and myocardial gas tensions with atrial pacing.

Myocardial carbon dioxide tension and intramyocardial S-T segment voltage have previously been shown to provide useful quantitative indexes of the severity of regional myocardial ischemia. This study was designed to determine if (1) changes in intramyocardial S-T segment voltage and myocardial gas tensions, with the addition of atrial pacing, could be used to assess the functional significance of a coronary stenosis, and (2) if changes in S-T voltage recorded in intramyocardial electrodes proved a more sensitive indicator of ischemia than changes recorded in epicardial electrodes. In 12 open chest dogs, a variable constrictor and an electromagnetic flow probe were placed on the proximal left circumflex coronary artery. Myocardial carbon dioxide and oxygen tensions were recorded with mass spectrometry and unipolar intramyocardial S-T segment voltage with multicontact plunge electrodes. Intramyocardial S-T voltage and myocardial carbon dioxide tension showed parallel increases with atrial pacing in the presence of subcritical, critical and supercritical coronary stenoses. In the presence of a critical stenosis, S-T segment changes recorded in deepr myocardial layers were of greater magnitude than those recorded near the epicardial surface. These findings suggest that the severity of myocardial ischemia can be assessed by measuring intramyocardial S-T voltage or myocardial gas tensions at resting and paced heart rates. They also suggest that intramyocardial S-T voltage is a more sensitive indicator of the severity of pacing-induced myocardial ischemia than epicardial S-T changes. Application of this technique to patients undergoing coronary revascularization could allow intraoperative determination of the functional significance of questionable angiographic lesions and a more rational approach to the assignment of priorities to individual arteries when multiple bypasses are being considered.

Effects of atrial pacing on regional myocardial gas tensions with critical coronary stenosis.

Changes in myocardial carbon dioxide (PmCO2) and oxygen tension (PmO2) measured by mass spectrometry have been shown to reflect quantitatively progressive degrees of regional myocardial ischemia associated with stepwise reduction in coronary blood flow. The present study utilized mass spectrometry to assess the severity of regional myocardial ischemia developing during atrial pacing in the presence of a flow-limiting proximal critical coronary artend subendocardial layers was measured by the radioactive microsphere technique. Application of a "critical stenosis" resulted in a 6-mmHg decrease in PmO2 and a 17-mmHg increase in PmCO2 in the region of the myocardium supplied by the stenosed vessel. The addition of atrial pacing resulted in a 3-mmHg further decrease in Pmo2 and a 40-mmHg further increase in PmCO2. In the region of myocardium supplied by the critically stenosed vessel MBF increased in the subepicardial layer, but decreased or remained unchanged in the subendocardial layer. The failure of myocardial blood flow to increase in deeper myocardial layers in response to the increased myocardial oxygen demand of atrial pacing would provide a mechanism for the development of subendocardial ischemia in the presence of a critical coronary stenosis.

The effect of cardiopulmonary bypass perfusion pressure on myocardial gas tensions in the presence of coronary stenosis.

Mass spectrometry was utilized to determine myocardial gas tensions in dogs subjected to cardiopulmonary bypass. Myocardial ischemia occurred in animals with normal coronary arteries when cardiopulmonary bypass perfusion pressure fell 40 to 60 mm Hg below the mean aortic pressure measured prior to bypass. Myocardial ischemia did not occur, or could be eliminated when present, if cardiopulmonary bypass perfusion pressure was maintained near prebypass mean aortic pressure. In animals with constricted circumflex coronary arteries, the adverse effect of low perfusion pressure on myocardial metabolism during cardiopulmonary bypass was found to be more severe in areas of myocardium supplied by the stenotic coronary artery. It is concluded that maintenance of cardiopulmonary bypass perfusion pressure near the level of preoperative mean aortic pressure will help prevent myocardial ischemia during operation; particularly in patients with coronary artery disease.

Changes in intramyocardial ST segment voltage and gas tensions with regional myocardial ischemia in the dog.

This study was designed to evaluate the sensitivity of changes in myocardial carbon dioxide and oxygen tensions as indicators of regional myocardial ischemia and also to determine to what extent these changes can be related to changes in intramyocardial ST segment voltage. Changes in ST segment voltage recorded in unipolar epicardial electrodes proved to be a less-sensitive indicator of underlying myocardial ischemia than were changes in ST segment voltage recorded in unipolar intramyocardial electrodes. In 9 dogs, regional ischemia was produced by placing a variable constrictor on the left circumflex coronary artery; circumflex flow was monitored. Myocardial carbon dioxide and oxygen tensions were measured using a mass spectrometer. Unipolar electrograms were recorded using a multicontact plunge electrode. With progressive degrees of proximal stenosis, ranging from a critical stenosis, which is associated with a decrease in mean flow of less than 15%, to a severe stenosis associated with and 80% decrease, ST voltage increased 21 mv and carbon dioxide tension increased 84 mm Hg, but oxygen tension decreased only 7 mm Hg. The study suggests that increases in intramyocardial ST segment voltage, an index of myocardial ischemia, are associated with parallel increases in myocardial carbon dioxide tension, each providing a more sensitive quantitative correlate of regional myocardial ischemia than do decreases in oxygen tension. The local accumulation of carbon dioxide may be an important pathophysiological mechanism in myocardial ischemia.