Impact of myocardial protection during coronary bypass surgery on patient outcome.

We have recently shown that continuous coronary perfusion with warm blood enriched with the ultra-short acting beta-blocker Esmolol (ES) improves functional and structural myocardial protection during coronary artery surgery as compared with conventional cardioplegia (CP). The purpose of the present study was to compare both myocardial protection techniques in terms of patient outcome. We retrospectively analyzed the charts of 150 consecutive patients subjected to coronary artery surgery using the ES-technique; 150 patients matched for age, gender, preoperative left ventricular function, history of renal failure, and history of neurological symptoms undergoing surgery with conventional CP during the same time period served as control group. There were no significant differences between both groups with respect to perioperative myocardial infarction rate, need for positive inotropic medication, need for mechanical circulatory support, duration of mechanical ventilation, duration of intensive care unit stay, time of mobilization, postoperative renal failure, cardiac arrhythmias, neurological symptoms, infections or in-hospital mortality. ES-patients were less frequently readmitted to the intensive care unit (ES: 3/150; 2.2% [95% confidence interval: 0-4.2%] vs. CP: 13/150; 8.7% [4.2-13.2%]; P=0.010) and total hospital stay was shorter (ES: 12.3+/-4.8 days [95% CI: 11.5-13.0] vs CP: 13.5+/-3.8 [12.9-14.1] days; P=0.0013), thus saving 159 patient days on the normal ward. Procedural costs were less for the ES-technique (US$ 60 per patient) as compared to the cardioplegia technique (US$ 120 per patient). These data suggest that myocardial protection using the ES-technique does not improve clinical outcome in patients subjected to routine coronary artery surgery, but may save costs.

Intracoronary shunt insertion prevents myocardial stunning in a juvenile porcine MIDCAB model absent of coronary artery disease.

OBJECTIVE: The relevance of regional LV myocardial ischemia/reperfusion induced by temporary left anterior descending (LAD) coronary artery occlusion during minimally invasive direct coronary artery bypass (MIDCAB) grafting is controversial. The purpose of our study was (1) to determine the impact of conventional LAD occlusion during left internal thoracic artery (LITA)-LAD anastomosis on regional LV myocardial ischemia and function, and (2) to evaluate if intra-LAD shunt insertion during LITA-LAD anastomosis prevents potential regional LV ischemia and dysfunction in a pig model. METHODS: In 20 anesthetized, mechanically ventilated pigs we performed LITA-LAD anastomosis on the beating heart without cardiopulmonary bypass during either 15 min LAD occlusion (occlusion-group; n = 10) or 15 min intra-LAD shunt insertion to maintain blood supply to the myocardium beyond the anastomosis (shunt-group; n = 10). Besides standard hemodynamics we determined the global and regional LV wall motion score index (WMSI) using epimyocardial echocardiography. To quantitate structural myocardial alteration we determined the inducible heat-shock protein-70 (HSP-70) in LV anterior wall myocardial biopsies. Data were recorded at baseline, at 15 min of LAD occlusion or shunt insertion, respectively, and at 30 min of reperfusion. At the end of the experiments we determined myocardial adenine nucleotide (ATP, ADP, AMP) and glycogen content. RESULTS: In both groups WMSI was not significantly different at 15 min LAD occlusion or shunt insertion, respectively, as compared to baseline. However, at 30 min reperfusion both global and regional WMSI demonstrated significant LV dysfunction in the occlusion-group, whereas LV function in the shunt-group remained normal. This was associated with higher myocardial HSP-70 expression in the occlusion-group (P < 0.05). Myocardial adenine nucleotide and glycogen contents were significantly better preserved in the shunt-group. CONCLUSIONS: Our data show that in a porcine MIDCAB model 15 min LAD occlusion and 30 min reperfusion result in significant myocardial stunning. In contrast, maintenance of LAD perfusion using intracoronary shunt insertion minimizes ischemia/reperfusion injury and prevents regional LV dysfunction. Although our experiments were conducted in healthy pig hearts absent from coronary artery disease, similar results may--at least partially--be expected in humans, and thus, intracoronary shunts could be a useful tool for myocardial protection during 'off-pump revascularization'.

Myocardial protection by pressure- and volume-controlled continuous hypothermic coronary perfusion in combination with Esmolol and nitroglycerine for correction of congenital heart defects in pediatric risk patients.

OBJECTIVE: This study assesses the technical applicability and the clinical value of the continuous coronary perfusion with oxygenated blood as a method for myocardial protection used for congenital heart surgery in pediatric risk patients. METHODS: Thirty non-consecutive pediatric risk patients aged from 1 month to 16 years (mean 3.9 years; 11/30 patients aged <6 months) underwent open heart procedures on the beating heart for simple and complex cardiac malformations using a self designed perfusion system with pressure- and volume-controlled continuous hypothermic coronary perfusion (PVC-CONTHY-CAP) in combination with ultra-short beta1-receptor blockade (Esmolol) and nitroglycerine for myocardial protection. The following procedures were done: VSD patch closure (n = 6), repair of total a-v canal with 'double patch' (n = 4), total repair of tetralogy of Fallot (n = 7), correction of truncus arteriosus communis type IV (n = 1), mitral valve reconstruction (n = 4), total cavo-pulmonary connection (n = 4), and Rastelli procedure (n = 4). RESULTS: The mean cardio-pulmonary bypass time was 131.5 min (range: 44-245 min), the mean coronary perfusion time: 90.1 min (range: 13-202 min). The weaning off extracorporeal circulation was uneventful in all patients, in 21 patients with low-dose and in nine patients with moderate catecholamine support: the mean weaning time was 25 min (range: 7 58 min). The post-operative mean peak creatine kinase (CK-MB) value was 58 U/l, (range: 14-202 U/l). The mean ICU stay in the cardiac surgery unit was 2.9 days, (range: 1-10 days). The mean post-operative mechanical ventilatory support was 2 days (range: 6 h-9 days). Six patients developed thrombocytopenia with values <40 tsd/microl, four patients renal dysfunction, two patients ascites, five patients heart rhythm disturbances, one patient neurological deficits. In three patients (VSD closure: n = 2; age: 1 and 2 months; total a-v-canal: n = 1; age: 3 months) re-do procedures for significant intraventricular shunt had to be done, in one patient implantation of a permanent pacemaker system was necessary. One patient died due to multiple organ failure after uneventful surgery (total cavo-pulmonary connection for single ventricle). CONCLUSIONS: PVC-CONTHY-CAP can be successfully used for repair of simple and complex congenital cardiac malformations. However, in children less than 3 months of age, the transatrial repair of intraventricular defects is technically much more demanding and challenging than under conventional cardioplegic arrest and is possibly accompanied by an increased incidence of residual or recurring intraventricular shunts.

Traumatic internal carotid artery dissection presenting as delayed hemilingual paresis.

A case of internal carotid artery dissection presenting as delayed right hemilingual paresis after blunt craniocervical trauma is presented. Diagnosis is discussed with emphasis on MR and MR angiographic findings. Mechanisms of injury and lower cranial nerve palsy are also briefly discussed.

Isolated cerebral intraaxial varix.

A case of isolated parenchymal venous varix not seen on angiography is reported. CT demonstrated a well-defined cystic lesion with peripheral enhancement deep within the left temporal lobe. MR demonstrated a high-signal-intensity lesion with hemosiderin rim.

Retroclival arachnoid cyst.

Retroclival arachnoid cyst is a rare mass lesion, with only seven cases previously reported in literature. MR is the imaging modality of choice in its evaluation and in its differentiation from epidermoid cyst. The case reported here was surgically proved and had an uncharacteristic MR signal intensity that was higher than that of cerebrospinal fluid due to previous hemorrhage.

Computerized tomographic scan findings in facial fractures associated with blindness.

A retrospective study of 379 consecutive patients who underwent operative repair of facial fractures at the West Virginia University Medical Center was carried out. Blindness developed in at least one eye in 21 (6%) of the 379 patients studied. Le Fort II and Le Fort III fractures, frontal bone and frontal sinus fractures, severe fractures of the zygoma, and fractures of the orbital floor were associated with fractures of the lesser sphenoid wing and optic canal in 5 of the patients studied. These 5 patients had indirect optic nerve injuries, as determined by CT scan and clinical criteria, which included visual loss with afferent pupillary defect and an otherwise normal ophthalmologic examination. In addition, one other patient who was not one of the 379 patients who underwent operative repair gradually developed ipsilateral blindness as a result of indirect optic nerve injury following minimal frontal bone trauma without a fracture. The usual mechanism of injury was trauma at the level of the orbital roof. The principal findings on CT scan were those of fracture of the lesser sphenoid wing and subdural hematoma of the optic nerve sheath. The association between sphenoethmoid sinus hemorrhage and fracture of the optic canal (31%) in cases of facial trauma has been presented. The indications for optic nerve decompression have been discussed. To the authors' knowledge, there is no previous report of an optic canal fracture as diagnosed by computerized tomography in the literature.

Case report. Nasopharyngeal mucormycosis.

Successful management of nasopharyngeal mucormycosis in a 58-year-old leukemia patient is reported. High index of suspicion, localizing the disease to the nasopharynx, early diagnosis by biopsy, control of underlying debilitating leukemia, and aggressive therapeutic approach all contributed to the successful outcome. Review of the literature indicates this to be the first reported case of successful outcome of mucormycosis in a patient with acute myelogenous leukemia. Application and findings of computed tomography for evaluation of mucormycosis are discussed.

Pituitary microadenoma: a radiological-surgical correlative study.

In this study, the authors evaluated the correlation between the radiological changes in the sella (using thin-section, complex motion tomography) and the location of pituitary microadenomas at surgery. A significant discrepancy was noted between the tomographic and surgical location of the tumor in 14 of 55 patients. The authors caution about absolute reliance upon tomography for making the diagnosis of pituitary microadenoma in a given patient.