Postoperative renal function preservation with nonischemic femoral arterial cannulation for thoracoabdominal aortic repair.

BACKGROUND: Renal failure after thoracoabdominal aortic repair is a significant clinical problem. Distal aortic perfusion for organ and spinal cord protection requires cannulation of the left femoral artery. In 2006, we reported the finding that direct cannulation led to leg ischemia in some patients and was associated with increased renal failure. After this finding, we modified our perfusion technique to eliminate leg ischemia from cannulation. In this article, we present the effects of this change on postoperative renal function. METHODS: Between February 1991 and July 2008, we repaired 1464 thoracoabdominal aortic aneurysms. Distal aortic perfusion was used in 1088, and these were studied. Median patient age was 68 years, and 378 (35%) were women. In September 2006, we began to adopt a sidearm femoral cannulation technique that provides distal aortic perfusion while maintaining downstream flow to the leg. This was used in 167 patients (15%). We measured the joint effects of preoperative glomerular filtration rate (GFR) and cannulation technique on the highest postoperative creatinine level, postoperative renal failure, and death. Analysis was by multiple linear or logistic regression with interaction. RESULTS: The preoperative GFR was the strongest predictor of postoperative renal dysfunction and death. No significant main effects of sidearm cannulation were noted. For peak creatinine level and postoperative renal failure, however, strong interactions between preoperative GFR and sidearm cannulation were present, resulting in reductions of postoperative renal complications of 15% to 20% when GFR was <60 mL/min/1.73 m(2). For normal GFR, the effect was negated or even reversed at very high levels of GFR. Mortality, although not significantly affected by sidearm cannulation, showed a similar trend to the renal outcomes. CONCLUSION: Use of sidearm cannulation is associated with a clinically important and highly statistically significant reduction in postoperative renal complications in patients with a low GFR. Reduced renal effect of skeletal muscle ischemia is the proposed mechanism. Effects among patients with good preoperative renal function are less clear. A randomized trial is needed.

Cardiac autotransplantation for surgical resection of a primary malignant left ventricular tumor.

Primary cardiac sarcomas are rare. In such tumors, surgical resection is sometimes considered necessary to correct obstruction of flow caused by the tumor and to accomplish complete resection. The anatomic difficulties associated with large, primary, intracavitary left-sided sarcomas have led us to use cardiac explantation, ex vivo tumor resection, and cardiac autotransplantation to meet the anatomic challenges of left atrial tumors. We report the case of a patient who had a large, primary, intracavitary, left ventricular sarcoma that was successfully removed by cardiac explantation and ex vivo reconstruction with use of the cardiac autotransplantation technique. This is the 1st report describing the use of cardiac autotransplantation to surgically resect an intracavitary left ventricular malignancy.

Heparin-induced thrombocytopenia associated with bilateral adrenal hemorrhage after coronary artery bypass surgery.

Heparin-induced thrombocytopenia (HIT) is a well-recognized syndrome associated with thrombosis and multiple potential clinical sequelae. We report a case of bilateral adrenal hemorrhage, a known but rare complication of heparin-induced thrombocytopenia complicating a routine coronary artery bypass surgery. Thrombocytopenia, abdominal pain, and signs of adrenal insufficiency in the context of heparin treatment should raise suspicion of this unusual complication.

Stentless bioprosthetic aortic valve replacement after a homograft root replacement: Toronto SPV implantation after a homograft root.

Stentless bioprosthetic valves for the aortic position offer excellent hemodynamic characteristics, making them an attractive choice ahead of other valve prostheses. We present a unique case in which a patient underwent aortic valve replacement with a stentless porcine valve and mitral valve repair for severe aortic and mitral regurgitation 1 year after a homograft root replacement for acute aortic endocarditis. The rationale for our approach is outlined in the context of current surgical trends.

Status of mitral valve surgery.

PURPOSE OF REVIEW: To review the evolution of mitral valve repair and outline currently favored repair techniques. RECENT FINDINGS: Chordal replacement with polytetrafluoroethylene sutures is an accepted and reproducible technique for repair of the anterior leaflet. Most posterior leaflet problems can be addressed with either a quadrangular resection or a sliding repair. SUMMARY: Mitral valve surgery has gradually evolved over the period of the last 50 years. Initially, most surgeons replaced the mitral valve in patients with regurgitant disease. It is now known, however, that long-term outcome for patients undergoing repair is superior to that for patients undergoing replacement. Mitral valve repair avoids the complications associated with the artificial valve and anticoagulation. The ability to reproducibly repair the mitral valve requires a detailed knowledge of the disease process and the reparative techniques. This article describes the current approach to mitral valve surgery and the important concepts necessary to achieve a durable repair.

Autotransplantation for central non-small-cell lung cancer in a patient with poor pulmonary function.

Lung resection is the standard therapy for non-small-cell lung cancer confined to the lung. The extent of pulmonary resection is dictated by the location and extent of the tumor and the patient's physiologic ability to tolerate resection. We present the case of a patient who had a large non-small-cell tumor of the lung that involved the right main stem bronchus and the adjacent pulmonary artery; poor pulmonary function precluded a pneumonectomy. Right upper and middle sleeve bilobectomy resection was performed, but reconstruction was not possible due to tethering by the intact lower lobe vein. Therefore, the remaining lower lobe was removed, and the lower lobe vein was divided and reimplanted into the upper lobe pulmonary venous stump. Cephalad advancement and autotransplantation of the lower lobe were then accomplished. These procedures allowed enough mobilization for direct bronchial and arterial reconstruction.

Current thinking in stentless valve surgery.

Aortic valve replacement for aortic stenosis represents a tremendous achievement in the management of cardiac disease. However, despite 4 decades of use, the ideal substitute for the diseased aortic valve is still not agreed upon. Stentless aortic valves represent the optimum in hemodynamic performance. This article reviews the current thinking in stentless aortic valve surgery.

Outcomes in single versus bilateral internal thoracic artery grafting in coronary artery bypass surgery.

The authors analyzed the early outcomes in two groups of patients undergoing coronary artery bypass grafting (CABG) with single versus bilateral internal thoracic arteries (ITA) in their institution. One thousand sixty-nine patients underwent CABG with single or bilateral ITAs from 1990 to 2000. Of these patients, 911 (85.2%) had single ITA and 158 had bilateral ITA (14.8%). The incidence of tobacco abuse was 40.3% in the single ITA group and 56.7% in the double ITA group (P = 0.0001). The incidence of perioperative myocardial infarction, renal failure, reoperation for bleeding, stroke, or operative mortality did not differ in the two groups. There was a 4.4% incidence of mediastinitis in the bilateral ITA group versus 2.2% in the single ITA group (P = 0.0602). Early outcomes after bilateral ITA grafting for CABG are similar to single ITA grafting. Careful judgment should be exercised in selecting patients for bilateral ITA grafting, particularly if the patient smokes.