Arie Schachner

Percutaneous tracheostomy: a new method

A rapid method of definitive low tracheostomy utilizing an original instrument kit and percutaneous approach is described. Through a horizontal, shallow (1.5-cm) skin incision in the neck, a 12-ga needle is introduced into the tracheal lumen. A flexible metal guidewire is gently introduced through the needle, which is then removed. A specially designed percutaneous tracheostomy tool slides over the guidewire into the trachea; by squeezing its handles, the intercartilaginous space is enlarged, securing the placement of a cuffed tracheal cannula. After extensive and successful investigation in both cadaver and animal trials, the procedure was carried out in 80 patients who had a variety of underlying diseases, without serious complications. Of these 80 patients, 33 required airway control after neurosurgical interventions or after severe head trauma, 23 had percutaneous tracheostomy performed before radical excision for head and neck cancer, and the remaining 24 suffered from severe cardiorespiratory problems. Twenty-nine procedures were performed in the operating theater, and 51 procedures were carried out at the patients bedside in the ICU, ED, or in the ward. There was no infection at the stoma site, and late healing was remarkable. It should be strongly emphasized that in the majority of our patients the procedure was carried out safely at the bedside. This resolved the logistic problem of moving very sick ICU patients (who are sometimes on high PEEP levels) to the OR. Although our experience is totally restricted to elective situations, we do postulate that it could be as effective in a variety of urgent situations.

Assessment of sternal vascularity with single photon emission computed tomography after harvesting of the internal thoracic artery.

OBJECTIVEnThis study prospectively evaluates the effect on sternal vascularity of harvesting the left internal thoracic artery.nnnMETHODSnTwenty-four consecutive patients undergoing primary coronary artery bypass grafting were studied. One patients procedure was altered during the operation, and he was eliminated from the study. The patients were prospectively randomized to receive a skeletonized internal thoracic artery (group I, n = 11) or a pedicled internal thoracic artery (group II, n = 12) graft. Each patient underwent a preoperative technetium 99 methylene diphosphonate bone scan using single photon emission computed tomography. The ratio of the mean counts per pixel on the left side of the sternum was compared with the mean counts per pixel on the right side. Postoperatively, all patients had a second scan, and sternal uptake was compared with the preoperative uptake.nnnRESULTSnNo significant differences in preoperative and operative variables were observed between the groups. A statistically significant reduction in blood flow to the left side of the sternum was shown postoperatively in group II compared with group I (0.61 +/- 0.11 vs 0.85 +/- 0.09; P <.001). Multivariable logistic regression analysis of preoperative and operative variables revealed only a pedicled left internal thoracic artery to be associated with a 20% or more reduction in left-to-right sternal activity ratio (odds ratio, 100; 70% confidence limits, 22-465; P =.002).nnnCONCLUSIONnA pedicled left internal thoracic artery graft to the left anterior descending artery reduces blood flow to the left side of the sternum during the acute postoperative period. This does not occur when the left internal thoracic artery is skeletonized.

Phrenic Nerve Injury After Coronary Artery Bypass Grafting: Will It Go Away?

BACKGROUNDnPhrenic nerve injury after coronary artery bypass grafting resolves in most cases. The purpose of this study was to analyze the causes and effects of persistent phrenic nerve injury after coronary artery bypass grafting.nnnMETHODSnFrom a registry of patients with chronic obstructive pulmonary disease who underwent coronary artery bypass grafting, 64 patients were identified who experienced phrenic nerve injury during their operation. Fifteen patients either died during follow-up (n = 9) or were lost to follow-up (n = 6). At the last follow-up visit, all the patients underwent an ultrasound evaluation of the diaphragm and were divided into those who had persistent dysfunction (group I) and those who had normal function (group II). The groups were compared for preoperative and operative risk factors, acute and midterm postoperative results, and quality of life at last follow-up.nnnRESULTSnThere were 13 patients in group I and 36 in group II. There were no significant differences in preoperative and operative risk factors between the groups. The length of hospitalization was similar for both groups (9.2 +/- 4.5 versus 8.5 +/- 3.3 days, respectively; p = 0.77). More patients in group I required reintubation (23% versus 14%, respectively; p = 0.04). The mean duration of follow-up was 32.7 +/- 9.2 months. At that time, both groups suffered a reduction of forced expiratory volume in 1 second compared with preoperative values. Group I had a greater reduction in forced expiratory volume in 1 second (p = 0.05). There were a total of 125 postoperative readmissions during the follow-up period, 36 in group I and 89 in group II. There were more admissions because of pulmonary problems in group I (85% versus 53%; p = 0.04). Of the 49 patients, 21 perceived a decline in quality of life after operation. More patients in group I (46% versus 22%; p = 0.05) complained of this decrease.nnnCONCLUSIONSnA significant number of patients who incur phrenic nerve injury after coronary artery bypass grafting have persistent phrenic nerve injury. Patients with persistent phrenic nerve injury have increased acute and midterm morbidity after operation, as well as reduced quality of life.

Carcinoma of lung with a solitary cerebral metastasis. Surgical management and review of the literature

During the years 1975 to 1980, 10 male patients and 1 female, with ages ranging between 40 to 61 years, underwent combined resection of primary lung cancer and solitary brain metastasis. In 8 patients the lung cancer was diagnosed and treated first. In those patients, craniotomy for removal of a solitary brain metastasis was carried out 8 to 60 months (mean, 27 months) after excision of the lung tumor. In 3 patients, brain metastasis was diagnosed and treated first and lung excision followed, 2 to 4 weeks after craniotomy. The most common histologic type of the tumor was adenocarcinoma (63.6%). There were no operative deaths. Three patients survived less than 6 months after surgery and were considered as a failure of surgical treatment. Seven patients lived longer than 1 year and three of them are still alive with a follow‐up period between 2 to 3 1/2 years after both operations. One of the patients underwent recently successfully second brain intervention for removal of recurrent histologically identical solitary brain metastasis and is well. Our results and those reported in literature encourage the combined surgical removal of primary lung cancer and a solitary brain metastasis.

Non-invasive measurement of cardiac output during coronary artery bypass grafting

OBJECTIVEnA new device, using whole body bioresistance measurements and a new equation for calculating stroke volume has been developed. Using this equation, an attempt was made to correlate whole body bioresistance cardiac output with thermodilution cardiac output in patients undergoing coronary artery bypass grafting.nnnMETHODSnThirty-one adults undergoing elective coronary artery bypass grafting were studied prospectively. Simultaneous paired cardiac output measurements by whole body bioresistance and thermodilution were made at five time points during coronary artery bypass grafting: in anesthetized patients before incision (T1), after sternotomy (T2), after opening the pericardium (T3), ten min post bypass (T4), and in the intensive care unit (T5). The patients had a mean of three thermodilution cardiac outputs compared with a mean of three bioimpedance measurements at each time point. The bias and precision between the methods were calculated.nnnRESULTSnThere was good correlation between bioresistance cardiac output (nCO) and thermodilution cardiac output (ThCO) measurements in both groups for all recorded times. The patients mean ThCO and nCO, as well as bias and precision between methods were calculated. Mean ThCO ranged between 4.14 and 5.06 l/min; mean nCO ranged between 4.12 and 4.97 l/ min. Bias calculations ranged between -0.072 and 0.104 l/min. Precision (2 SD) calculations ranged between 0.873 and 1.228 l/min for 95% confidence intervals. Pearsons correlation ranged from 0.919 to 0.938.nnnCONCLUSIONSnCardiac output measured with the new device correlates well with the thermodilution measurements of cardiac output during and immediately following coronary artery bypass grafting. The overall agreement between the two methods was good. The new device is an accurate non-invasive method of measuring cardiac output during coronary artery bypass grafting.

Myocardial Protection in Infant Open Heart Surgery

Myocardial protection was evaluated in 2 groups of 5 infants each undergoing correction of either tetralogy of Fallot (TOF) or subcristal ventricular septal defect (VSD). In group A, profound hypothermia and total circulatory arrest (PHTCA) was utilized. In group B, profound hypothermia and total circulatory arrest combined with potassium cardioplegia (PHTCA + K) was the method of protection used. The analysis was carried out by sequential measurements of clinical, electrocardiographic, enzymatic (CK-MB) and ultrastructural parameters. There were no operative deaths. One infant had a second operation for recurrent VSD. The average anoxic time was 35.4 min in group A (PHTCA) and 32.6 min in group B (PHTCA + K). Analysis of our data demonstrated that when potassium cardioplegia was added to PHTCA, there was less intraoperative myocardial damage according to physiological, ultrastructural and biochemical parameters than when profound hypothermia and total circulatory arrest was applied alone.

Retrograde (Atrial) Dislodgement of a Cross–Jones Mitral Valve Occluder

Fatal atrial dislodgement of a lenticular disc occurred seven years after surgery in a 54-year-old patient, who had had a mitral valve replacement with a Cross-Jones prosthesis, for ruptured chordae tendinae. A marked distortion of the titanium ring reinforced silicone rubber lens disc due to material wear was the cause of this complication. From the literature available to us, atrial dislodgement of a prosthetic mitral occluder has not been previously recorded. We therefore intend to recommend elective replacement of the Cross-Jones prosthesis in all patients who have had their artificial valve functioning for more than five years.

Removal of deadspace volume from arterial catheter: How muchis enough?

Objective To evaluate the amount of volume needed to be removed from arterial catheter systems to compensate for “deadspace” and to allow an accurate measurement of pH and hemoglobin (Hb). Design Twenty patients undergoing heart surgery were evaluated in a steady state after the induction of anesthesia before surgery. Six blood samples were removed from the arterial catheter, the total volume of which was 1.5 mL at 30-sec intervals and measured for pH and Hb. The first sample was then taken after removing 1.5 mL from the tubing. In subsequent samples, the volume removed before sampling increased by 0.5-mL intervals. All other samples were compared with sample number 6, in which 4 mL of volume were removed before measurements. Results The first three samples with volumes of 1.5, 2.0, and 2.5 mL before measurement were inaccurate compared with sample number 6 (p < .000), giving artificially low values for both pH and Hb. There was no significant difference between the values measured in sample numbers 4, 5, and 6 (3.0, 3.5, and 4.0 mL, respectively). Conclusion The amount of volume needed to be removed before measurement from an arterial catheter system, the volume of which is 1.5 mL, is 3 mL to achieve accurate measurements of pH and Hb. Removal of less volume results in an artificially low measurement.

Interaction of thyroid hormone and heparin in postischemic myocardial recovery

BACKGROUNDnTriiodothyronine (T3) administration can improve postischemic myocardial recovery. Heparin can interfere with cellular binding of T3. Introduction of heparin into an isolated heart model may interfere with this effect.nnnMETHODSnFour groups of 8 rat hearts were placed on a modified Langendorff apparatus. All groups underwent 15 minutes of perfusion with modified Krebs-Henseleit solution (KH), followed by 20 minutes of normothermic global ischemia and 30 minutes of reperfusion. Group I underwent reperfusion with KH. Group II underwent reperfusion with KH and 1 x 10(-6) mol/L of T3. In group III, hearts underwent preischemic perfusion with heparinized KH (1,000 U/L) and reperfusion with KH containing 1 x 10(-6) mol/L of T3 and 1,000 U/L of heparin. In group IV, rats were given heparin at 2,000 IU/kg 30 minutes before sacrifice, and isolated hearts were reperfused with KH and 1 x 10(-6) mol/L of T3. A latex balloon in the left ventricle monitored hemodynamic variables.nnnRESULTSnLeft ventricular developed pressure throughout postischemic reperfusion was greater in all the groups receiving T3 when compared with group I. Group II showed significantly greater recovery than either group III (p < 0.05) or group IV (p < 0.05).nnnCONCLUSIONSnAddition of T3 to the reperfusate enhances postischemic myocardial recovery in the isolated heart model, whereas addition of heparin reduces this effect.

Repair of coarctation of the aorta in the first three months of life.

Coarctation of the aorta was surgically treated in 28 infants (16 male, 12 female) aged 2 days-3 months, with 19 younger than 1 month. Body weight at operation was 1.6-4.2 (mean 2.8) kg. 3 infants had coarctation alone, 10 had a wide patent ductus arteriosus as the only associated anomaly and 15 had a variety of other anomalies. Resection with end-to-end anastomosis was performed in only one case, while 21 underwent subclavian flap aortoplasty and six patch graft aortoplasty. Additional procedures were banding of the pulmonary artery in five cases and open aortic commissurotomy in one case. The early mortality was 10.7% (3 infants) and three more died later. Further cardiac surgery was subsequently performed on four of the infants. Of the 22 survivors, two had significant recurrence of coarctation which, however, was successfully corrected in one case. The blood pressure was within normal limits in all survivors, except those with recoarctation.