A. C. Fiore

Cardiac surgery in the octogenarian

The increasing safety of cardiac surgery has led to the frequent referral of octogenarians for operation. Between 1980 and 1989, we reviewed our experience with 103 octogenarians (59 male, 44 female; mean age 82 years) to determine the surgical risk factors and outcome in the elderly population. There were 71 coronary bypasses (CABG), 11 aortic valve replacements (AVR), 11 AVR-CABG, 4 mitral valve replacements (MVR), 3 MVR-CABG and 3 AVR-MVR-CABG. Seventeen patients died during hospitalization (16.5%) including 9 CABG (13%); 1 AVR (9%), 2 AVR-CABG (18%), 2 MVR (50%), 1 MVR-CABG (33%) and 2 AVR-MVR-CABG (67%). Statistical analysis of 22 perioperative variables suggested that a preoperative intraaortic balloon, a history of congestive heart failure, mitral valve replacement, urgent operation, need for preoperative inotropic support and the number of anastomoses performed were significant or marginally significant (P less than 0.15) univariate predictors of operative mortality. Multivariate analysis revealed that the need for a preoperative intraaortic balloon (F = 13.1), history of congestive heart failure (F = 6.8), and MVR (F = 6.7) were significant (P less than 0.001) independent predictors of mortality. Postoperative complications included arrhythmias in 36 patients (35%), respiratory insufficiency in 11 (11%), reversible neurological deficit in 15 (14%), and a permanent neurological deficit in 6 patients (6%). Actuarial survival was 90% and 82% at 1 and 2 years, respectively. Seven of 86 (8%) long term survivors sustained a stroke in the follow-up interval. The mean follow-up of survivors was 23 +/- 19 months with a mean improvement in NYHA class of 1.4 (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Pericardial drainage: subxiphoid vs. transthoracic approach.

The optimal management of effusive pericardial disease remains controversial. Subxiphoid drainage has been criticized for a high recurrence rate while transthoracic procedures (window or pericardiectomy) are more invasive operations with greater potential for morbidity. We compared subxiphoid (SX group) and transthoracic (TT group) drainage in 131 patients (age range from 1 month to 81 years) treated from 1979 to the present. The etiology of effusion included cancer (38), uremia (24), infection (27), radiation (9), and other (33) causes. The two groups had similar age and sex distribution, etiology, and fluid volume. There was no difference in the operative mortality between the two groups (SX 15%, TT 13%, p = NS). Patients undergoing thoracotomy for treatment of effusive pericardial disease had a higher incidence of respiratory complications as defined by the presence of pneumonia, pleural effusion, prolonged ventilation, and need for reintubation (SX 11%, TT 35%, p less than 0.005). This may account, in part, for the longer mean hospital stay in transthoracic group (14.4 vs. 11.4 days). Nine patients were lost to follow-up after hospital discharge. The remaining 104 hospital survivors were followed for between 1 month and 11 years (mean 34 months, cumulative of 297 patient years). Three patients in each group experienced fluid recurrence and all but one were successfully treated by needle aspiration or percutaneous catheter placement. Following discharge, no patient required reoperation for effusive or constrictive pericardial disease or died from tamponade. There were no significant differences in 5-year actuarial survival (SX 54%, TT 49%) or actuarial freedom from recurrence (SX 89%, TT 93%).(ABSTRACT TRUNCATED AT 250 WORDS)

Fifteen-year follow-up for double internal thoracic artery grafts.

The internal mammary artery (IMA) is the conduit of choice for myocardial revascularization. From 1972 to 1989, 586 patients received bilateral IMA and supplemental vein grafts. There were 506 men (86%) and 79 women (14%) with a mean age of 55.5 years (range 32-77 years). Unstable angina was present in 138 patients (24%), insulin-requiring diabetes mellitus in 83 (14%) and previous myocardial infarction (MI) in 25 (4%). Preoperative angiography demonstrated triple-vessel disease in 286 patients (49%) and double-vessel disease in the remaining 300 patients (51%). Left main coronary artery disease (stenosis greater than or equal to 50%) was present in 53 (9%). The mean left ventricular score was 7.4 with a range of 5 to 20. The mean number of grafts performed was 3.4 per patient. Hospital mortality was 3.6% (21 patients). Follow-up was done through direct patient contact, via the patients physician or by telephone contact with the patient themselves or surviving family members. Follow-up was complete in 518 hospital survivors and ranged from 1 month to 17.5 years with a cumulative follow-up of 911 patient years. At 10 and 15 years, respectively, the actuarial freedom from MI was 78% and 72% and freedom from reoperation was 93% and 86%. Actuarial survival at 10 and 15 years was 85% and 70%, respectively. This longitudinal analysis demonstrates that bilateral IMA grafting has a low operative risk. The data suggest that utilization of two IMA grafts yield excellent freedom from recurrent symptoms and provides excellent long-term survival.

Revascularization with bilateral internal thoracic artery grafts in patients with left main coronary stenosis.

Left main occlusive disease (LMD) is a potentially fatal lesion which is optimally treated with surgical revascularization. Although the internal thoracic artery (ITA) is recognized as having superior long term patency, there has been concern regarding possible flow limitation. Because of this concern, there may be reluctance to use only this conduit in patients with LMD in whom high graft flows are desirable. From 1985 to 1990, 45 patients (38 males, 7 females) with LMD ranging in age from 37 to 75 years (mean 55.9 +/- 8.7) underwent revascularization using bilateral ITA grafts placed to the left anterior descending and circumflex arteries. The right ITA was used as a free graft in 19 of 45 (42%) patients and the left ITA was used as a free graft in 3 of 35 (7%). No saphenous vein grafts were placed to the left coronary system in any patient. Over half of these patients (24 patients, 53%) also had occlusive disease in the right coronary artery. A saphenous vein graft was placed to the right coronary artery in 22 of 45 (49%) patients. Ventricular function in this patient subset was good (mean LV score 7.1 +/- 2.1). Intra-operative ITA graft flows were 49.7 +/- 29.1 ml/min for grafts to the left anterior descending and 45.5 +/- 31.7 ml/min for circumflex grafts. There were no perioperative deaths. Morbidity included myocardial infarction, stroke and reoperation for bleeding in 1 patient each (2.2%). Low cardiac output occurred in 2 patients (4.4%). No patient had a mediastinal wound infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Venous prostheses: Improved patency with external stents

A uniformly successful prosthesis for replacement in the venous system has not been developed. This study assesses the effect of external stents on the patency of polytetrafluoroethylene (PTFE) grafts in the infrarenal vena cava. Under general anesthesia, 21 mongrel dogs underwent midline laparotomy. The infrarenal vena cava was resected and replaced by a standard segment (8 cm X 10 mm) of stented PTFE (12 dogs) and nonstented PTFE (9 dogs). Patency was assessed by contrast venography and the results compared between the two groups. The 7-, 30-, and 90-day patency was 12/12, 10/12, and 9/12, respectively, for stented PTFE and 6/9, 2/9, and 2/9, respectively, for nonstented PTFE. The patency of externally stented PTFE at 30 and 90 days was significantly better than grafts fashioned from PTFE alone (P less than 0.05 by chi-square analysis). These data demonstrate that external stenting improves the early patency of PTFE prostheses in the infrarenal vena cava. Consideration should be given to the clinical use of externally stented PTFE when prosthetic replacement in the venous system is required.

Isthmus Flap Aortoplasty: An Alternative to Subclavian Flap Aortoplasty for Long-Segment Coarctation of the Aorta in Infants

The ideal operation for infants with coarctation of the aorta remains controversial. Subclavian flap aortoplasty is the most popular technique for this age group. The 5 to 20% recurrence rate is attributed to regrowth of the coarctation web or inadequate length of the subclavian flap, particularly when the aortic isthmus is long and narrow. Severe arm ischemia following subclavian flap aortoplasty, although rare, is a disturbing complication. The purpose of this study is to report the results with a new technique we call isthmus flap aortoplasty for coarctation of a long segment of the aorta in infants. This technique avoids the limitations of subclavian flap aortoplasty. A short segment of aorta, including the ductal entrance and coarctation web, was resected in 4 infants (mean age, 35.5 days) with long-segment coarctation. The posterior wall of the long isthmus was opened longitudinally to the level of the transverse aortic arch. The descending aorta was mobilized and advanced to the level of the aortic arch where the posterior half was sutured. The anterior flap of attached isthmus was then sewn into a longitudinal incision made in the anterior wall of the descending aorta. All infants survived this procedure and had no gradient at completion of the repair. The mean transconduit gradient at rest was zero and rose to 7.0 +/- 0.93 mm Hg after angiography at a mean follow-up of 42 months. Aortograms demonstrated that the reconstructed area had grown in girth and attained a normal caliber in each child.(ABSTRACT TRUNCATED AT 250 WORDS)

Inferior epigastric artery for myocardial revascularization.

From March 1990 through January 1992, 108 patients undergoing myocardial revascularization had one (91) or both (17) inferior epigastric arteries (IEA) used for myocardial revascularization. The internal thoracic artery (ITA) was used bilaterally in 87 patients. Of the 373 distal anastomoses, 210 (56%) were with the ITA, 130 (35%) with the IEA, and 12 (3%) with the gastroepiploic artery. Nineteen patients (18%) received 21 saphenous veins. When compared with the ITA, the IEA demonstrated a longer harvest time (36.5 vs 29.6 min, P < 0.0001), a shorter usable length (11.9 cm vs 16.5 cm, P < 0.001), and similar flow (49.7 cc/min vs 48.7 cc/min, P = NS). The operative mortality was 2.8%. Two deaths resulted from low cardiac output and the one remaining death from complications of a cerebral vascular accident. The most common major complication was respiratory insufficiency, which occurred in 11 patients (12%). There were two sternal infections (2%), and two abdominal wound infections (2%), none of which were fatal. The IEA is an acceptable additional arterial conduit. It can be safely employed with one or both ITAs. Short-term and long-term patency must be established before preferential use of this conduit is advised.

Coronary ostial stenosis

Symptomatic, nonsyphilitic, acquired coronary ostial stenosis is a rare angiographic finding and was found in 0.13% of 3000 coronary angiograms. Three females with this lesion have been treated surgically. Two had left coronary ostial involvement. Coronary angiography may result in catheter tip occulsion of the ostium with chest pain, dyspnea, diaphoresis, systemic hypotension and abrupt fall in pressure at the catheter tip. Recognition of this entity is necessary for safe coronary angiography. Involvement of the left ostium carries the same serious prognosis as does left main coronary disease.

Double-valve replacement with Medtronic-Hall or St. Jude valve

To define better the performance of the bileaflet St. Jude and the tilting-disc Medtronic-Hall valves, we retrospectively analyzed 122 patients (St. Jude, 80 patients; Medtronic-Hall, 42 patients) who received simultaneous aortic and mitral replacement from May 1984 until June 1994. The two groups were not different with respect to preoperative clinical and hemodynamic parameters and New York Heart Association functional class. The hospital mortality and late mortality were not significantly different. Risk analysis identified advanced age and previous myocardial revascularization as predictors of operative death. Follow-up was complete in 96 of 103 hospital survivors (93%) and was similar in both groups. The actuarial survival, linearized rates of valve-related complications, and actuarial freedom from valve-related complications were similar in both cohorts. The presence of coronary artery disease negatively influenced the actuarial survival after simultaneous aortic and mitral valve replacement. Postoperative New York Heart Association functional class was not significantly different in either group. These data indicate that the Medtronic-Hall and St. Jude prostheses are not significantly different with respect to their clinical performance and valve-related complications for simultaneous double-valve replacement.

The prevention of extra cardiac conduit obstruction: An experimental study

Acquired right ventricular (RV) extracardiac conduit (ECC) obstruction was studied in an animal model. A 16 mm woven Dacron tube graft was inserted between the right ventricle (RV) and main pulmonary artery (PA) in 18 adult mongrel dogs followed by pulmonary artery occlusion with a Dacron tape. In 9 dogs, the RV anastomosis was maintained with a 16 mm Dacron covered polypropylene stent. The remaining 9 animals with direct suture attachment of the graft to the myocardium served as controls. Cardiac output and transconduit resistance were measured at operation, 6 months, and 1 year. The cardiac output remained the same in both groups. Animals with stented ECC showed little change in transconduit resistance and had a widely patent RV anastomosis at 1 year. Unstented conduits had increased transconduit resistance at 6 months and 1 year (P less than 0.002). Postmortem examination showed fibromuscular ingrowth of the ventricular anastomosis to be the site of the acquired obstruction in unstented extracardiac conduits. The inclusion of a rigid stent in RV-ECC may warrant clinical application to prevent fibromuscular ingrowth and late RV anastomotic obstruction.