Surgical ventricular reconstruction and subendocardial resection for the treatment of refractory ventricular tachycardia.

We describe a case of 64-year-old female patient with ventricular tachycardia intractable to medical treatment and acute heart failure following myocardial infarction. Emergency surgical ventricular reconstruction and subendocardial resection was undertaken. We discuss the option of surgical intervention in this difficult and unusual clinical scenario.

Patients undergoing cardiac surgery with asymptomatic unilateral carotid stenoses have a low risk of peri-operative stroke.

BACKGROUND: There is considerable controversy regarding the optimal management of patients undergoing cardiac surgery who are found to have an asymptomatic, unilateral carotid artery stenosis. Prior to 2004, the policy of this Unit was to perform a synchronous cardiac and carotid revascularisation. After January 2004, the policy was changed and patients underwent their cardiac procedure without carotid revascularisation. The aim of this study was to audit the incidence of stroke in the peri-operative period following this change in practice. METHODS: Five-year audit of the 30-day risk of stroke after 61 consecutive open cardiac procedures in patients with unilateral, asymptomatic 70-99% (NASCET) stenoses who did not undergo prophylactic carotid endarterectomy. RESULTS: 61 cardiac procedures; coronary artery bypass grafting (CABG)=44, valve replacement=6, CABG+valve replacement=9, CABG+repair of left ventricular aneurysm=2 were undertaken and the 30-day outcomes audited. There were three deaths (4.9%), all due to myocardial infarction. No strokes occurred in any patient in the 30-day post-operative period. CONCLUSION: These results challenge the opinion that the presence of a unilateral, asymptomatic carotid stenosis in patients undergoing open cardiac surgery is associated with an increased risk of peri-operative stroke, sufficient to warrant routine prophylactic carotid revascularisation.

Video-assisted thoracoscopic implantation of the left ventricular pacing lead for cardiac resynchronization therapy.

BACKGROUND: To study the feasibility and efficacy of video-assisted thoracoscopic (VAT) placement of the left ventricular pacing lead for cardiac resynchronization therapy (CRT) where the conventional transvenous coronary sinus approach has failed. METHODS: Seventeen patients underwent the VAT procedure. Indications for CRT were ischemic cardiomyopathy in six patients and nonischemic cardiomyopathy in 11. The procedure was performed under general anesthesia with single-lung ventilation. Three 2-cm incisions were used on the left chest wall to place the screw-in lead near the obtuse marginal arteries high on the lateral wall of the left ventricle (LV). RESULTS: The VATS approach was successful in 13/17 (76%) patients. Median procedure time was 75 minutes (range 55-135). A learning curve was observed that appeared to plateau at 75 minutes procedure time after four cases. Median length of hospital stay was 2 days (range 2-8) with one patient requiring intensive care. Satisfactory thresholds and impedances of 2.3 +/- 0.9 V/0.5 ms and 560 ohms, respectively, were achieved at mean follow-up of 226 days. All patients reported symptomatic benefit with reduction in New York Heart Association score from III preoperatively to II postoperatively. CONCLUSIONS: VAT placement of the epicardial pacing lead is feasible, safe, and efficacious. It should be considered in cases where the transvenous route has failed or as an alternative in prolonged or hazardous transvenous procedures.

Non-invasive measurement of peripheral venous oxygen saturation using a new venous oximetry method: evaluation during bypass in heart surgery.

Monitoring of mixed venous oxygen saturation (SvO(2)) is currently performed using invasive fibre-optic catheters. This procedure is not without risk as complications may arise from catheterization. This paper describes an alternative, non-invasive method of monitoring peripheral venous oxygen saturation (SxvO(2)) which, although it cannot replace pulmonary artery catheters, can serve as an adjunct/early warning indicator of when there is an imbalance in oxygen supply and demand. The technique requires the generation of an artificial venous pulse at the finger, thereby causing modulation of the venous blood volume within the digit. The blood volume changes are monitored using an optical sensor. Just as pulse oximetry utilizes the natural arterial pulse to perform a spectrophotometric analysis of the peripheral blood in order to estimate the arterial blood oxygen saturation, the proposed venous oximetry technique uses the artificially generated venous pulse to estimate SxvO(2). A prototype device was tested in a pilot study with patients undergoing heart surgery. Data from this study support the notion that the method is capable of tracking haemodynamic changes and suggests the technique is worthy of further development and evaluation.

Preoperative intra aortic balloon pumps in patients undergoing coronary artery bypass grafting.

BACKGROUND: The intra aortic balloon pump (IABP) is a mechanical assist device which improves cardiac function. The device has a well-established place in algorithms for managing low cardiac output following cardiac surgery. There is increasing evidence that certain cardiac surgery patients benefit from a period of preoperative augmentation with the intra aortic balloon pump. OBJECTIVES: To determine the effect of the preoperative intra aortic balloon pump on mortality and morbidity in a number of different patients groups undergoing coronary artery bypass grafting. SEARCH STRATEGY: Searches were performed of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 1 2005), MEDLINE (2000-2005) and EMBASE (1998-2005). No language restrictions were applied. SELECTION CRITERIA: Randomised or controlled trials of any size or length were included. DATA COLLECTION AND ANALYSIS: Papers were assessed for inclusion by two reviewers independently. Differences were settled by consensus with a third reviewer. Data were extracted and entered into RevMan 4.1, through which a meta-analysis of the data was performed. MAIN RESULTS: Five randomised controlled trials were identified from a total of 765 studies (4 on-pump and 1 off-pump). Data from a total of 193 patients were included in the meta-analysis; all on-pump. Generally, the patients were designated as "high risk" . 105 patients were treated preoperatively with IABP and 88 patients served as controls. There were three hospital deaths in the intervention arm and 18 in the non-intervention arm (odds ratio (OR) 0.16; 95% confidence intervals (CI): 0.06 to 0.4; P<0.0001). Low cardiac index (<2.0 L/min/m2) was noted in 21 out of 105 patients in the treatment arm and 59 patients out of 88 in the non-treatment arm (OR 0.14; 95% CI: 0.08 to 0.25; P<0.00001). A large proportion of the control group had an IABP inserted postoperatively for low cardiac index (52 out of 88). An off-pump versus on-pump analysis was not possible due to the limited number of off-pump studies. However a single well-conducted randomised controlled trial suggested favourable effect of the preoperative IABP in off-pump patients. AUTHORS' CONCLUSIONS: Available evidence suggests the preoperative intra aortic balloon pump may have a beneficial effect on mortality and morbidity in specific high risk patient groups undergoing coronary artery bypass grafting, however, the randomised evidence is from a number of small trials, with a high proportion of unstable patients, recruited at a single institution.

Mitral valve repair for active culture positive infective endocarditis.

OBJECTIVE: To describe the clinical and echocardiographic outcome after mitral valve (MV) repair for active culture positive infective MV endocarditis. PATIENTS AND METHODS: Between 1996 and 2004, 36 patients (mean (SD) age 53 (18) years) with positive blood culture up to three weeks before surgery (or positive culture of material removed at operation) and intraoperative evidence of endocarditis underwent MV repair. Staphylococci and streptococci were the most common pathogens. All patients had moderate or severe mitral regurgitation (MR). Mean New York Heart Association (NYHA) class was 2.3 (1.0). Follow up was complete (mean 38 (19) months). RESULTS: Operative mortality was 2.8% (one patient). At follow up, endocarditis has not recurred. One patient developed severe recurrent MR and underwent valve replacement and one patient had moderate MR. There were two late deaths, both non-cardiac. Kaplan-Meier five year freedom from recurrent moderate to severe MR, freedom from repeat operation, and survival were 94 (4)%, 97 (3)%, and 93 (5)%, respectively. At the most recent review the mean NYHA class was 1.17 (0.3) (p < 0.0001). At the latest echocardiographic evaluation, left atrial diameters, left ventricular end diastolic diameter, and MV diameter were significantly reduced (p < 0.05) compared with preoperative values. CONCLUSIONS: MV repair for active culture positive endocarditis is associated with low operative mortality and provides satisfactory freedom from recurrent infection, freedom from repeat operation, and survival. Hence, every effort should be made to repair infected MVs and valves should be replaced only when repair is not possible.

Complications related to intra-aortic balloon pump in cardiac surgery: a decade later.

BACKGROUND: Our centre in 1995 reported 26% of vascular complications in cardiac surgical patients treated with intra-aortic balloon pump (IABP). However, during the last decade there have been improvements in IABP technology and insertion techniques. We aimed to evaluate the impact of these changes on the incidence of IABP-related complications in cardiac surgery. METHODS: Demographics, indications, technique and complication rate in 186 consecutive patients treated with IABP from January 1994 to December 1998 (Group I) were compared with 323 consecutive patients treated with IABP from January 1999 to December 2003 (Group II) at our regional cardiothoracic centre. Data was variably expressed as mean with or without range and either standard deviation or range. Statistical significance was accepted at P<0.05. RESULTS: There were 121 (65%) and 194 (60%) males in Group I and II, respectively. The mean age was 66+/-12.1 (17-88) years and the mean duration of IAPB use was 43.5h (range 3-144 h). Overall complication rate was 10% in Group I and 2% in Group II whereas vascular complications accounted for 3% in Group-I and 1% in Group-II. Logistic regression analysis demonstrated cardiogenic shock being strongly correlated to in-hospital mortality (OR 4.68; P=0.004) followed by older age (OR 3.12; P=0.034) and ejection fraction <35% (OR 1.78; P=0.03). CONCLUSION: The study demonstrated a significant decrease in the IABP-related complications even though complexity of cases referred for surgery has increased. Henceforth, the risk of 1% vascular complications should play little influence on decision-making regarding the use of IABP.

A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery.

OBJECTIVES: To compare the clinical- and cost-effectiveness of minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous transluminal coronary angioplasty (PTCA) with or without stenting in patients with single-vessel disease of the left anterior descending coronary artery (LAD). DESIGN: Multi-centre randomised trial without blinding. The computer-generated sequence of randomised assignments was stratified by centre, allocated participants in blocks and was concealed using a centralised telephone facility. SETTING: Four tertiary cardiothoracic surgery centres in England. PARTICIPANTS: Patients with ischaemic heart disease with at least 50% proximal stenosis of the LAD, suitable for either PTCA or MIDCAB, and with no significant disease in another vessel. INTERVENTIONS: Patients randomised to PTCA had local anaesthetic and underwent PTCA according to the method preferred by the operator carrying out the procedure. Patients randomised to MIDCAB had general anaesthetic. The chest was opened through an 8-10-cm left anterior thoracotomy. The ribs were retracted and the left internal thoracic artery (LITA) harvested. The pericardium was opened in the line of the LAD to confirm the feasibility of operation. The distal LITA was anastomosed end-to-side to an arteriotomy in the LAD. All operators were experienced in carrying out MIDCAB. MAIN OUTCOME MEASURES: The primary outcome measure was survival free from cardiac-related events. Relevant events were death, myocardial infarction, repeat coronary revascularisation and recurrence of symptomatic angina or clinical signs of ischaemia during an exercise tolerance test at annual follow-up. Secondary outcome measures were complications, functional outcome, disease-specific and generic quality of life, health and social services resource use and their costs. RESULTS: A total of 12,828 consecutive patients undergoing an angiogram were logged at participating centres from November 1999 to December 2001. Of the 1091 patients with proximal stenosis of the LAD, 127 were eligible and consented to take part; 100 were randomised and the remaining 27 consented to follow-up. All randomised participants were included in an intention-to-treat analysis of survival free from cardiac-related events, which found a non-significant benefit from MIDCAB. Cumulative hazard rates at 12 months were estimated to be 7.1 and 9.2% for MIDCAB and PTCA, respectively. There were no important differences between MIDCAB and PTCA with respect to angina symptoms or disease-specific or generic quality of life. The total NHS procedure costs were 1648 British pounds and 946 British pounds for MIDCAB and PTCA, respectively. The costs of resources used during 1 year of follow-up were 1033 British pounds and 843 British pounds, respectively. CONCLUSIONS: The study found no evidence that MIDCAB was more effective than PTCA. The procedure costs of MIDCAB were observed to be considerably higher than those of PTCA. Given these findings, it is unlikely that MIDCAB represents a cost-effective use of resources in the reference population. Recent advances in cardiac surgery mean that surgeons now tend to carry out off-pump bypass grafting via a sternotomy instead of MIDCAB. At the same time, cardiologists are treating more patients with multi-vessel disease by PTCA. Future primary research should focus on this comparison. Other small trials of PTCA versus MIDCAB have now finished and a more conclusive answer to the original objective could be provided by a systematic review.

Postoperative extracorporeal membrane oxygenation for severe intraoperative SIRS 10 h after multiple trauma.

A 34-yr-old male suffered multiple trauma in a road traffic accident. He required right thoracotomy and laparotomy to control exanguinating haemorrhage, and received 93 u blood and blood products. Intraoperatively, he developed severe systemic inflammatory response syndrome (SIRS) with coagulopathy and respiratory failure. At the end of the procedure, the mean arterial pressure (MAP) was 40 mm Hg, arterial blood gas analysis showed a pH of 6.9, Pa(CO(2)) 12 kPa, and Pa(O(2)) 4.5 kPa, and his core temperature was 29 degrees C. There was established disseminated intravascular coagulation. The decision was made to stabilize the patient on veno-venous extracorporeal membrane oxygenation (ECMO) only 10 h after the accident, in spite of the high risk of haemorrhage. The patient was stabilized within 60 min and transferred to the intensive care unit. He was weaned off ECMO after 51 h. He had no haemorrhagic complications, spent 3 weeks in the intensive care unit, and has made a good recovery.

Lung volume reduction surgery--a comparison of the long term outcome of unilateral vs. bilateral approaches.

OBJECTIVE: Bilateral lung volume reduction surgery (LVRS) is thought to be preferable to unilateral surgery due to greater initial benefit but the subsequent rate of decline may also be greater. We compared the long term physiological and health status outcome of LVRS performed on one or simultaneously on both lungs. METHODS: Prospective data were collected on a consecutive series of 65 patients undergoing LVRS who were all suitable for bilateral surgery. Twenty-six patients: age 59 (8) years underwent bilateral LVRS by video-assisted thoracoscopy (VAT) or sternotomy and 39 patients: age 60 (6) years underwent unilateral VAT. The perioperative effects of LVRS on spirometry were prospectively recorded at 3, 6, 12 and 24 months. RESULTS: The unilateral group had similar preoperative lung volumes to the bilateral patients: forced expiratory volume in 1s (FEV(1)) 26 vs. 30% predicted, RV 275 vs. 246% predicted and total lung capacity (TLC) 148 vs. 142% predicted. Unilateral LVRS was associated with significantly lower weight of lung resected: 80 (31) vs. 118 (46) g; hospital stay: 16 (10) days vs. 28 (22) days. Thirty-day mortality was 3% in the unilateral and 8% in the bilateral group (P=0.34). Postoperative ventilation occurred in 5% in the unilateral and in 42% in the bilateral group (P=0.0002). The decline of FEV(1) during the first postoperative year was significant in the bilateral group (-313 ml/y, P=0.04) but not significant in the unilateral group (-50 ml/y, P=0.18). SF 36 scores in all eight domains were similar in both groups preoperatively and at any postoperative interval. CONCLUSION: We have found no benefit from bilateral simultaneous LVRS and prefer unilateral LVRS because of the lower morbidity, resulting in earlier discharge, and slower decline in physiological benefit.

Risk factors for intestinal ischaemia in cardiac surgical patients.

OBJECTIVE: Mesenteric ischaemia is an uncommon (<1%) but serious complication of cardiac surgery associated with a mortality >50%. Predictors of this complication are not well defined, and diagnosis can be difficult and prompt surgical intervention can be lifesaving. METHODS AND RESULTS: In a retrospective case-note analysis from May 1994 through to May 2000, we identified mesenteric ischaemia in 39 of 5349 consecutive patients (0.07%) undergoing cardiac surgery with cardiopulmonary bypass. By logistic multivariate analysis, we have identified six possible predictors of intestinal ischaemia: duration of cross-clamp, use of significant inotropic support, intra-aortic balloon counterpulsation for low cardiac output, need for blood transfusions, triple vessel disease and peripheral vascular disease. In all patients a combination of four predictors were present. Patients who survived this complication had surgical intervention earlier (6.4+/-3.8 h) than those who did not (16.9+/-10 h). CONCLUSIONS: The diagnosis and prompt treatment of mesenteric ischaemia post cardiac surgery requires a high degree of awareness. These predictors may be useful in alerting medical staff to the possibility of gastro-intestinal ischaemic complications after cardiac surgery particularly that early surgical intervention reduces mortality.

Midterm evaluation of the Tissuemed (Aspire) porcine bioprosthesis: 493 patients, 506 bioprostheses.

BACKGROUND: Valve durability has been a major concern with bioprostheses, and the Tissuemed (Aspire) porcine bioprosthesis was designed to provide a solution to structural valve failure. Because bioprostheses tend to fail by 8 years, the aim of our study was to determine its midterm durability and performance. METHODS: We reviewed 506 prostheses that were implanted in 493 patients (287 men; mean age 73 +/- 6 years) between 1991 and 1999. Preoperatively 316 (68%) patients were in New York Heart Association class III or IV. There were 417 (85%) aortic, 61 (12%) mitral, 13 (2.6%) aortic and mitral, and two (0.4%) tricuspid procedures. Concomitant procedures were performed in 163 (33%) patients. Follow-up was complete in 488 (98.9%) patients with a total cumulative follow-up of 1,402 patient-years. RESULTS: The 30-day mortality in this elderly population was 10% (95% confidence interval, 8 to 13), with no early valve-related deaths. Patients' survival at 8 years was 46% +/- 7%. This was influenced by the following factors: (1) the patient's age, being worse for those 70 years or older (p = 0.005); (2) those in New York Heart Association functional class III and IV (p = 0.004); (3) those in atrial fibrillation before the operation (p = 0.006); (4) those with poor left ventricular function (p = 0.009); and (5) those who had a previous cardiac operation (p = 0.003). Valve-related complications (expressed as percent per patient-year) were thromboembolism at 0.9%/patient-year; major hemorrhage at 1.4%/patient-year; bacterial endocarditis at 0.4%/patient-year; nonstructural dysfunction at 0.2%/patient-year, and reoperation at 0.2%/patient-year. At 8 years, freedom from thromboembolism was 93% +/- 7%, major hemorrhage, 90% +/- 4%, nonstructural dysfunction, 99% +/- 1%, structural valve failure, 100%, and reoperation, 99% +/- 1%. At follow-up, 98% of survivors were in New York Heart Association class I or II. CONCLUSIONS: Our study suggests that at 8 years, the Tissuemed (Aspire) porcine bioprosthesis is durable and has satisfactory performance with low complication rates.

Reliability of Allen's test in selection of patients for radial artery harvest.

BACKGROUND: Allen's test is widely used to assess the ulnar collateral blood supply of the hand before radial artery harvest for coronary bypass surgery. This study was performed to determine the optimum cut-off point for a positive Allen's test and the clinical reliability of Allen's test in this role. METHODS: Patients undergoing coronary artery bypass surgery were examined by independent observers using both Allen's test and a Doppler ultrasound test of the ulnar collateral circulation. RESULTS: We examined 93 hands in 47 patients; mean age was 63.6 years. Receiver operating characteristic analysis found that at a conventional cut-off of 6 seconds on Allen's test had a sensitivity of 54.5%, specificity of 91.7%, and diagnostic accuracy of 78.5%. At a cut-off of 5 seconds diagnostic accuracy was maximal (79.6%), with sensitivity of 75.8% and specificity of 81.7%; 100% sensitivity occurred at a cut-off of 3 seconds, with specificity of 27% and diagnostic accuracy of 52%. CONCLUSIONS: At no cut-off point does Allen's test perform satisfactorily as a discriminatory test. It should be replaced by more objective tests, such as Doppler ultrasound.

Prognostic factors for malignant mesothelioma in 142 patients: validation of CALGB and EORTC prognostic scoring systems.

BACKGROUND: The incidence of malignant mesothelioma is increasing. There is the perception that survival is worse in the UK than in other countries. However, it is important to compare survival in different series based on accurate prognostic data. The European Organisation for Research and Treatment of Cancer (EORTC) and the Cancer and Leukaemia Group B (CALGB) have recently published prognostic scoring systems. We have assessed the prognostic variables, validated the EORTC and CALGB prognostic groups, and evaluated survival in a series of 142 patients. METHODS: Case notes of 142 consecutive patients presenting in Leicester since 1988 were reviewed. Univariate analysis of prognostic variables was performed using a Cox proportional hazards regression model. Statistically significant variables were analysed further in a forward, stepwise multivariate model. EORTC and CALGB prognostic groups were derived, Kaplan-Meier survival curves plotted, and survival rates were calculated from life tables. RESULTS: Significant poor prognostic factors in univariate analysis included male sex, older age, weight loss, chest pain, poor performance status, low haemoglobin, leukocytosis, thrombocytosis, and non-epithelial cell type (p<0.05). The prognostic significance of cell type, haemoglobin, white cell count, performance status, and sex were retained in the multivariate model. Overall median survival was 5.9 (range 0-34.3) months. One and two year survival rates were 21.3% (95% CI 13.9 to 28.7) and 3. 5% (0 to 8.5), respectively. Median, one, and two year survival data within prognostic groups in Leicester were equivalent to the EORTC and CALGB series. Survival curves were successfully stratified by the prognostic groups. CONCLUSIONS: This study validates the EORTC and CALGB prognostic scoring systems which should be used both in the assessment of survival data of series in different countries and in the stratification of patients into randomised clinical studies.

Post infarction ventricular septal defect - can we do better?

OBJECTIVE: To identify predictors of early and late outcome among 117 consecutive patients who underwent postinfarction ventricular septal defect (VSD) repair over a period of 12 years. METHODS: A retrospective analysis of clinical data was performed. Mean age was 65.5+/-7.8. There were 43 females. Full data were obtained in 110 patients. Of these, 76 patients presented with anterior and 34 with posterior VSD. Thirty-three patients were operated in cardiogenic shock. Mean time between myocardial infarction (MI) and VSD development was 5.6+/-7.8 days (median 4) and from VSD to surgery 9. 0+/-28.1 (median 2). Sixty-six patients had intraaortic balloon pump (IABP) inserted, and 15 were ventilated preoperatively. Logistic regression and Cox regression were used for multivariate analysis. RESULTS: Thirty days mortality was 37%. Among 110 patients, in whom complete analysis was possible, 38 died within 30 days (35%). Mortality in the posterior VSD group was 35% and in the anterior VSD group 34% (NS). In 44 patients (40%) a residual shunt was found on postoperative echocardiography. This required reoperation in 13 patients (four deaths). Cardiogenic shock prior to surgery adversely influenced early survival - odds ratio (OR) 5.7 (confidence interval (CI) 2.1-16.0) (P=0.0008). Deterioration of haemodynamic status in between admission and surgery was stronger predictor of mortality than shock on admission - OR 6.0 (CI 1.6-22.6) (P=0.008) vs. 3.1 (CI 1.0-9.3) (P=0.049). A longer time between MI and surgery favoured survival - OR 0.1 (CI 0.03-0.4) (P=0.002). The time period from the infarct to the septal rupture, but not from the rupture to surgery, appeared to be a significant predictor of survival - OR 0.2 (CI 0. 05-0.6) (P=0.008). Five years survival was 46+/-5%. Preoperative cardiogenic shock affected late survival - OR 2.7 (CI 1.5-4.9) (P=0. 001). Of 72 patients who survived 30 postoperative days, 12 (17%) were in New York Heart Association (NYHA) class III or IV and five (6.9%) in Canadian Cardiovascular Soceity (CCS) class III or IV at the last follow-up. CONCLUSIONS: Preoperative cardiogenic shock and early postinfarction septal rupture carry a grave prognosis. Achieving haemodynamic stability prior to surgery may be beneficial but prolonged attempts to improve patients' cardiovascular state are hazardous.