Combined open heart surgery and replacement of the brachiocephalic trunk. A safe method for simultaneous central revascularization.

OBJECTIVE: We investigated the feasibility of open heart surgery with combined central vascular surgery and present the results from 9 years of experience. PATIENTS AND METHODS: Of a total of nine patients, eight received coronary artery bypass grafting and one patient aortic valve replacement. Concerning vascular surgery a replacement of the brachiocephalic trunk using a Dacron prosthesis as an end-to-end anastomosis or as a bifurcations prosthesis was performed. Two patients underwent additional ipsilateral desobliteration of the internal carotid artery. RESULTS: The hospital stay was between 8 and 30 days (median 15). The duration of the whole operation was median 318 min (range: 294-345 min), perfusion time 67 min (range: 62-146 min), myocardial ischemic time 27 min (range: 11-83 min). There was no case of in-hospital death. Follow-up was available up to 7.5 years in 7 patients. Five patients show a satisfactory cardiac status. A sign for ischemic cerebral events or embolization was not observed. CONCLUSION: Due to the low complication rate, we conclude that concomitant open heart surgery with replacement of the brachiocephalic trunk can be performed with low risk; it allows-in contrast to direct endarterectomy-complete central revascularization and hence should be preferred compared to surgical therapy in separate settings.

[Simultaneous surgical intervention for occlusion of the internal carotid artery and coronary disease--reasonable or high-risk combination?]. / Simultane operative Behandlung von A. carotis interna-Stenosen und koronarer Herzerkrankung. Sinnvolle oder zu risikoreiche Kombination?

BACKGROUND AND OBJECTIVE: Carotid artery stenosis as risk factor for postoperative stroke after cardiac surgery is confirmed in recent publications. Nevertheless indications for combined procedures in carotid occlusive disease and coronary artery disease are discussed controversely in the literature. Based on our own experiences since 1992 the risk factors are reviewed. PATIENTS AND METHODS: The data of 104 patients (80 male, 24 female, age 67 +/- 7 years), with 106 combined operations performed between 1992 and 1999, were evaluated retrospectively. 36% of the patients had symptomatic and 64% had asymptomatic carotid artery stenosis. RESULTS: Seven patients (6.6%) developed postoperative neurological deficits. One patient (1.0%) died as result of a stroke. In three patients a stroke occurred in the ipsilateral hemisphere, whereas two of three patients with cerebral infarction in the contralateral hemisphere had no significant carotid artery stenosis on this side. One patient had multiple bilateral embolism. Cardiac complications occurred in seven patients (6.6%). The inhospital mortality for non-stroke related complications was 3.8%, the total mortality 4.8%. CONCLUSION: From our experiences the combined approach for carotid artery occlusive disease and coronary artery disease can be recommended in selected patients. The rate of complications seems to be lower than in staged procedures. The spontaneous course of the disease can be improved and the patient is spared a second operation.

Change of sternal perfusion following preparation of the internal thoracic artery--a scintigraphical study.

BACKGROUND: Today the internal thoracic artery (ITA) is the bypass graft of choice due to its superior long-term patency rate. It was the aim of this present prospective study to investigate possible perfusion disturbances and consecutive impaired wound healing induced by the ITA preparation. The sternal perfusion was assessed by bone scintigraphy. METHODS: Forty-four patients were included in the study. There were three groups: group I (control, no ITA preparation; n = 12); group II (preparation of the left ITA; n = 21); group III (preparation of both ITAs; n = 11). In all patients a median sternotomy was performed. A bone scintigraphy was performed 4 days before and 12 days after the bypass procedure. Scintigraphical pictures of all patients were assessed visually (one specialized investigator) and the impulse rate was counted by the aid of a computer program. RESULTS: Results of both evaluation methods showed congruently that neither the use of the left nor of both ITAs causes a statistically significant impairment of sternal perfusion. The percentage of postoperative increase of the rate of impulses was in group I: total sternum 55%; right side 56%; left side 55%. The respective numbers for group II were 58, 63 and 53%, and for group III 54, 52 and 56%. Surprisingly, perfusion scans in group II revealed an increase in the right sternal half after left ITA preparation. This may be due to the additional blood flow demand of collaterals branching between the right ITA and contralateral intercostal arteries representing a compensatory mechanism of the loss of the left ITA. During the observed postoperative time frame (mean 15 days) no healing disturbance of the sternal wound occurred in any patient. CONCLUSION: According to the present data the use of one or both ITAs does not cause an increase of healing disturbances, consecutive to a postoperatively decreased sternal blood perfusion.

Longterm efficiency of high dose inotropic support in an infant after repair of Fallot's tetralogy.

A 23 month old boy with highly symptomatic tetralogy of Fallot (TOF) underwent repair. Inspite of cold Bretschneider cardioplegic solution twice the heart was beating soon after application of the cardioplegic solution each time. Soon after transfer to the intensive care unit the patient developed low cardiac output (LCO). The following days high doses of inotropic support ware necessary to maintain sufficient arterial pressure. The dosages of dobutamine (up to 49 micrograms/kg/min); norepinephrine (up to 5.28 micrograms/kg/min, and epinephrine (up to 16 micrograms/kg/min), respectively, were twice and three times as high as common maximum recommendations. After having recovered from acute renal failure requiring hemodialysis from the 5th to the 37th postoperative day the child was discharged 9 weeks after the intervention. The very unusual and interesting course of this boy is described and the form and grade of the inotropic support is discussed.

Left aortic arch and right descending aorta--interruption or severe coarctation of the aortic arch in the newborn.

Three consecutive neonates (aged 7, 14 and 30 days, body-weight 2980 g, 3000 g and 3400 g respectively) with interruption of the aorta (n = 2) and severe coarctation (n = 1) in the presence of left aortic arch and right descending aorta are reported. Associated lesions were an aortopulmonary window in the first case and an unrestrictive ventricular septal defect in the two others. Intractable heart failure and the complexity of the malformation led to the decision of a staged operation. A prosthetic graft was interposed between the ascending and descending aorta via a right thoracotomy in order to bridge the atretic or hypoplastic segment without using extracorporeal circulation. There was no intraoperative complication. One patient developed a thrombocytopenia within the frame of a sepsis syndrome and died on day 5 after operation, death being caused by a massive bleeding into the left thoracic cavity, although the operation was carried out via a right thoracotomy. Angiography 1 year after operation revealed a good flow through the grafts and no stenosis at the site of the anastomoses. The two surviving infants are clinically well without any medication. The reported operative technique provides an alternative palliative possibility to manage critically ill neonates without any obstacle to later definitive repair.

[Acute coronary artery occlusion after elective percutaneous transluminal coronary angioplasty. Incidence and therapy in 5000 consecutive patients]. / Akuter Koronargefässverschluss nach elektiver perkutaner transluminaler Koronarangioplastie. Inzidenz und Therapie bei 5000 konsekutiven Patienten.

Five thousand consecutive percutaneous transluminal coronary angioplasties (PTCA) were electively performed between January 1988 and June 1993. They were analysed for the incidence of acute coronary occlusion, its acute treatment and subsequent course. In 133 patients (2.7%) the occlusion persisted. Recanalization by repeat PTCA was attempted in all of them, but succeeded in only 68 (51%). In 65 patients recanalization was impossible. In 25 of the latter--patients with a small infarct vessel and infarction having already occurred in the vessel's supply area while the haemodynamics remained stable--conservative treatment was practised. Acute surgical revascularization was undertaken in 30 patients (23%) with a large area and/or haemodynamic instability. In all, 14 patients died (overall death rate 0.28%, death rate of patients with occlusion 11%), ten of them before operative intervention was possible.--Not all coronary artery occlusions can be treated nonsurgically. Consequently, availability of surgical intervention at the place of elective PTCA is mandatory.