The axillocoronary bypass. Blood flow and short-term graft histology in a porcine model.

BACKGROUND: Bypass grafts arising from the axillary artery may be indicated for complications during minimally invasive direct coronary artery bypass grafting, for redo operations and for management of a severely atherosclerotic ascending aorta. As basic data research on this technique is scanty, we investigated intraoperative function and postoperative morphology of axillocoronary bypass grafts in a porcine model. METHODS: Thirteen German domestic pigs received an axillocoronary vein graft (Group I, n=7) or an aortocoronary vein graft (Group II, n=6) to the left anterior descending artery. In Group I the proximal anastomosis was performed to the left axillary artery, and after partial rib resection the graft was brought transpleurally to the target vessel. In both groups the coronary anastomosis was carried out on the beating heart without cardiopulmonary bypass. Graft flow was measured using transit time ultrasonic flow probes. RESULTS: Intraoperatively all grafts showed a typical diastolic flow profile. Stable graft flow was lower in axillocoronary bypass grafts: 47 (30-60 mL/min) in Group I and 65 (35-126 mL/min) in Group II (p=0.005). Flow given as percentage of cardiac output, however, did not differ between the two grafts: 0.9 (0.6-1.2%) in Group I and 1.2 (0.8-2.4%) in Group II (p=NS). At day 4 after surgery there was no clear histologic predilection site for microtrauma and early degenerative changes in the axillocoronary graft. CONCLUSIONS: Axillocoronary bypass flow compares well with flow in the aortocoronary graft. Microtrauma after implantation and early degenerative changes in the axillocoronary vein bypass are not particularly impacted by the thoracic entry site.

[Variability of coping strategies in coronary artery bypass surgery patients]. / Zur Variabilität des Coping bei Patienten mit aortokoronarer Bypass-Operation.

The state-versus-trait discussion in coping research would become more meaningful if attention is paid to the variability both of coping patterns in individual patients as well as stability of single coping strategies over time. 35 patients undergoing coronary artery bypass surgery were interviewed three times about their coping and stress experience: after cardiac catheterization, on the day before surgery, and six days after surgery. Anxiety and depression were measured. A coping attitude of "positive passivity" was present at all three points of time. While the group means were stable, vast interindividual differences occurred. Also, there was a high degree of scatter in the stability of single coping items; emotion related coping modes were more stable than cognition and action related ones. The variability of the patients' coping patterns correlated positively with the amount of stress experienced and with preoperative depression. Different coping strategies are linked to a different degree with personality traits, emotional coping modes revealing the closest connection. The variability of individual coping efforts might be linked to a personality disposition characterized by a vulnerability for stress and depressive reactions.

Beating heart axillocoronary bypass for management of the untouchable ascending aorta in coronary artery bypass grafting.

OBJECTIVES: Cannulation and clamping of a severely atherosclerotic ascending aorta during coronary artery bypass grafting (CABG) can lead to cerebral embolization of atheromatous debris and should therefore be avoided whenever possible. A variety of surgical techniques including performance of extraanatomical coronary bypass conduits has been described to solve this problem. We report on a preliminary series of four patients in whom the axillary artery was used as an inflow vessel for venous coronary artery bypass grafts which were performed on the beating heart in order to achieve an aortic no touch concept. METHODS: The axillary artery was exposed between the pectoralis major muscle and the deltoid muscle via an infraclavicular incision. A saphenous vein graft of at least 40 cm in length was sutured to the axillary artery and then brought into the pericardial cavity following an intercostal and transpleural route. The graft was anastomosed to the target vessel using local coronary occlusion. The procedure was carried out via sternotomy in three patients who also received additional internal mammary artery in situ grafts for adequate coronary revascularization. In one high risk patient an isolated axillocoronary bypass was performed in a minimally invasive fashion via anterolateral minithoracotomy. RESULTS: The procedure was completed without major technical difficulties in all four patients. The mean graft length required was 33.2 +/- 1.6 cm, postoperative ultrasonic duplex scans of the axillocoronary grafts revealed a mean flow of 62.5 +/- 23.6 ml/min. No stroke or brachial plexus injury occurred. Three patients are in angina class I (Canadian Cardiovascular Society Classification), one patient is in class II postoperatively. After a mean follow-up of 11.5 +/- 6.6 months postoperatively all grafts remain patent. CONCLUSION: Axillocoronary bypass grafting can be easily performed for management of the untouchable ascending aorta. Straightforward surgical technique and the accessibility to noninvasive diagnostics seem to offer advantages over other extraanatomical bypass grafts.

Elective surgery for blunt cardiac trauma.

The cases of eight patients who underwent elective surgery for blunt cardiac trauma are presented. All but one experienced multiple trauma and the median Injury Severity Score was 26 (range, 18-59). A posttraumatic cardiac defect was diagnosed from 1 day up to 6.5 years (median, 3 weeks) after the accident. These included mitral regurgitation (n = 4), ventricular septal defect (n = 2), atrial septal defect with mitral regurgitation (n = 1), and ventricular aneurysm (n = 1). Elective cardiac surgery was performed from 4 weeks up to 12 years after the traumatic event (median, 18.5 months). A history of blunt chest trauma requires careful clinical follow-up supported by echocardiography in asymptomatic patients. Surgical therapy is performed according to standard techniques and the results are comparable with those of non-trauma surgery.

Early experience with sequential bilateral lung transplantation.

We performed 20 sequential bilateral lung transplantation in 19 consecutive patients from April 1990 to May 1992. Perioperative mortality was low (2 patients). One-year actuarial survival was 70%. All survivors had normal blood oxygen tension (82 mm Hg, mean) while breathing room air and continuing improvement of pulmonary function. Bronchial dehiscence did not occur. Stents were implanted in 7 patients to control bronchial stenosis. Aggressive treatment of graft rejection has been effective in preventing obliterative bronchiolitis.

Successful lung transplantation in a long-term ventilator-dependent patient.

Ventilator dependence has been postulated to be a major contraindication for successful lung transplantation. We describe the case of a 44-year-old female patient mechanically ventilated for 10 months after adult respiratory distress syndrome. After a program of physical training the patient underwent successful bilateral sequential lung transplantation. Six months postoperatively she is in good physical condition and is able to carry out the activities of normal daily living. We conclude that in selected patients long-term mechanical ventilatory support is not a contraindication for lung transplantation.

Closed circuit perfusion of an isolated rabbit lung. A new model for the evaluation of preservation quality of stored lungs.

The comparison of different preservation methods in lung transplantation demands a well standardized and reproducible animal model. The aim of this study was to establish as in vitro model in which the oxygenation capacity of the lung can be investigated over an extended period of time. Heart-lung blocks from 6 New Zealand white rabbits were harvested, the pulmonary artery and the left ventricle cannulated and the lungs perfused with whole rabbit blood by means of a roller pump and ventilated with room air. A dialyser was installed into the closed circuit perfusion for continuous deoxygenation of the oxygen-saturated blood gained from the left ventricle. Throughout the stable perfusion period the average arterial and venous partial oxygen pressure (pO2) levels were 105.8 +/- 15.5 mmHg and 55.2 +/- 6.2, respectively (P < 0.05). The average peak airway pressure steadily increased from 10.7 +/- 1.2 mmHg at the start of reperfusion to 21 +/- 14.4 mmHg after 180 minutes (P = NS). With this experimental setting it is possible to maintain stable conditions (i.e. constant venous and arterial blood gases) for at least 180 minutes. It is therefore feasible to compare the influences of different preservation methods on the quality of lung function.

Management of severe bronchial ischemia after bilateral sequential lung transplantation.

A case of severe diffuse bronchial ischemia after bilateral sequential lung transplantation is presented. A combination of initial conservative treatment with silicone stenting and late bilateral retransplantation under stable conditions resulted in good clinical outcome. Factors in decision making and technical aspects of the stenting procedure are discussed.

[Surgery of blunt heart trauma]. / Zur Chirurgie des stumpfen Herztraumas.

Between 1972 and 1990 11 patients--all but one of them with multiple injuries--were treated surgically for blunt cardiac trauma caused by traffic accident in about 90%. Myocardial rupture (n = 3), laceration of the pericardial sac (n = 1), mitral insufficiency (n = 5; one of them in combination with atrial septal defect), ventricular septal defect (n = 1) and myocardial aneurysm (n = 1) occurred. Patients with myocardial rupture and pericardial laceration died within 2 h after admission to hospital; the other patients were successfully treated by mitral valve replacement (n = 4), mitral valvuloplasty and repair of ASD, suture repair of VSD and resection of myocardial aneurysm in one case, respectively. The interval to operation was 8 months to 12 years. Whereas pericardial tamponade caused by rupture of the atrial or ventricular wall and injuries of main coronary vessels require immediate surgical intervention, valve insufficiencies, septal defects or myocardial aneurysms may be mostly treated at a later date. Improvement of logistic measurements and the suspicion of blunt cardiac trauma followed by immediate surgical intervention may reduce the mortality rate in cases of cardiac rupture.

One and one-half year experience with unilateral and bilateral lung transplantation.

Lung transplantation has now become an established form of treatment for end-stage pulmonary parenchymal and vascular diseases. Despite its wide acceptance, technical aspects are still in discussion. We report on the initiation of our own lung transplant program and the technical changes we have performed during our first 1 1/2-year experience. During that period of time, we have performed 26 lung transplantations (16 single lung [SLTX] and 10 bilateral lung transplantations [BLTX]). Three-month survival for the whole group was 74% (69% for the SLTX group and 77% for the BLTX group). No instance of bronchial dehiscence was observed; however, there were eight cases of bronchial stenosis: six were managed by silicone stent insertion, one by bronchoplastic correction, and one by retransplantation. Changes in the technique of the bronchial anastomosis together with the addition of prednisone to the immediate postoperative immunosuppressive regime resulted in almost complete avoidance of these problems.