Berkeley Brandt

Delineation of the extent of coronary atherosclerosis by high-frequency epicardial echocardiography.

Postmortem studies suggest that coronary angiography does not always accurately delineate the extent of coronary-artery disease. We examined this problem in living human hearts by performing high-frequency epicardial echocardiography at the time of cardiac surgery. The ratio of the diameter of the lumen of the coronary artery to the thickness of its wall was used to quantify the severity of coronary lesions. In 11 patients with no angiographic evidence of coronary disease anywhere in the coronary tree, the mean (+/- SEM) ratio was 5.9 +/- 0.3. In 21 patients with angiographic disease at the site evaluated by echocardiography, the mean ratio was lower (2.3 +/- 0.2, P less than 0.05), reflecting encroachment into the arterial lumen by atherosclerotic plaque. In 15 patients with arterial segments that were angiographically normal but with arterial stenoses elsewhere in the coronary tree, the mean ratio was 4.1 +/- 0.3, with marked overlap with the values in the patients who had angiographic disease at the site of the echocardiographic evaluation. These results demonstrate, in living human hearts, that diffuse coronary atherosclerosis is often present when coronary angiography reveals only discrete stenoses. This finding suggests that coronary angiography may underestimate the severity and extent of coronary disease.

Anomalous Origin of the Right Coronary Artery from the Left Sinus of Valsalva

ANOMALOUS origin of the right coronary artery from the left sinus of Valsalva is a rare congenital abnormality. For many years pathologists classified it as a minor anomaly of no clinical importance. Recently, manifestations of myocardial ischemia have been described in patients with this anomaly in the absence of additional atherosclerotic or other disease processes. These manifestations have included acute myocardial infarction, angina pectoris, syncope, nonfatal ventricular fibrillation, and sudden death.1 2 3 4 5 6 Although clinical, anatomic, and angiographic data suggest impaired physiologic function of an anomalous right coronary artery that originates from the left sinus of Valsalva, no actual physiologic measurements have .xa0.xa0.

Surgical Treatment of Atrial Myxomas: Early and Late Results of 11 Operations and Review of the Literature

Eleven patients underwent surgical excision of atrial myxomas during a 15-year period, with no hospital deaths. The operation consisted of excision of the tumor with a generous portion of atrial septum or wall. Patch reconstruction of the atrial septum was required in most patients. There were 2 late deaths (14 and 121 months after operation). Late recurrences have been reported in other series but no recurrences were diagnosed in any of the patients in this series reexamined by echocardiography 7 to 156 months (mean, 48 months) after operation. Late functional results were excellent (78%, New York Heart Association Class D. The pertinent literature is reviewed.

Ventricular Septal Defect Following Myocardial Infarction

Review of the literature since 1970 revealed more than 200 patients who had a ventricular septal defect following myocardial infarction and underwnet operation. Pathogenesis and diagnosis are discussed. The primary therapy is operative repair, which is considered from the standpoint of approach, timing, technique, concomitant coronary artery bypass, mortality, and long-term survival. Operative mortality in those patients operated on less than 3 weeks following perforation remains high (40%) but when it is possible to wait 3 weeks, there is a marked decrease in mortality (6%). Several general principles have evolved for the care of these patients. (1) Operation should be deferred until 3 weeks after infarction if possible. (2) The intraaortic balloon allows preoperative evaluation of the patient with clinical hemodynamic deterioration in the early postinfarction period. (3) The incision should be placed through the infarct. (4) Associated coronary artery or mitral valve disease should be repaired as well.

Bronchial Carcinoid Tumors

Forty-six patients with bronchial carcinoid tumors were operated on over a 37-year period. The results were reviewed with special reference to presenting complaint, histological diagnosis, location of the tumor, lymphatic involvement, and type of surgical resection. Age at operation ranged from 9 to 86 years (mean, 43.6 years). Presenting symptoms were hemoptysis in 21 instances, chronic cough in 17, and pneumonia in 15. The primary tumor was within the main bronchus in 17 patients. Twenty-one patients required pneumonectomy, and 20 had lobectomy or bilobectomy . Nine of the patients under-going pneumonectomy had severely damaged lung tissue distal to the lesion in the main bronchus. Six patients had metastases to hilar nodes. Four patients died of carcinoid tumor, but none with metastases died of carcinoid tumor. This series confirms the low malignancy potential of bronchial carcinoid tumors, even in the presence of lymphatic involvement. Although conservative resection is an attractive surgical option, only 10 of the 46 (22%) were potential candidates for such intervention. Standard surgical resection resulted in cure in 90% of the patients in the series.

Scalene node biopsy in advanced carcinoma of the cervix uteri

To determine the incidence of scalene node metastasis from carcinoma of the cervix uteri, all patients with advanced carcinoma of the cervix who underwent scalene node biopsy as part of a pretreatment evaluation at the University of Iowa Hospitals and Clinics have been reviewed. In 40 patients, left scalene node biopsy was indicated because of (1) metastatic para‐aortic nodes (25); (2) palpable scalene nodes (2); and (3) other evidence of metastasis or unresectability. Of the 25 patients with metastasis to para‐aortic nodes, seven (28%) had metastasis to the scalene node. None of these was palpable preoperatively. Because scalene node involvement indicates that the disease is beyond the scope of both surgical and radiation treatment, routine scalene node biopsy is recommended in those patients with para‐aortic node metastasis.

Intraoperative High-Frequency Epicardial Echocardiography in Coronary Revascularization: Locating Deeply Embedded Coronary Arteries

During coronary revascularization, the precise location of major coronary arteries may be obscured by overlying fat, myocardial bridging, or epicardial scarring. High-frequency epicardial echocardiography can be used intraoperatively to quickly image and locate such arteries and eliminate the need for time-consuming epicardial exploration or potentially deleterious retrograde probing of distal coronary artery branches. This technique can be applied using commercially available equipment and the aid of a skilled technician.

Ligation of Patent Ductus Arteriosus in Premature Infants

In the operating room, 66 preterm infants weighing between 710 and 2,700 gm (23 less than 1,000 gm) underwent ligation of a patent ductus arteriosus (PDA). Respiratory distress syndrome was present in 53 patients; the rest had apnea-bradycardia syndrome. PDA ligation was indicated for intractable congestive heart failure in 52 patients or progressive respiratory failure in 14. There were no intraoperative deaths. Fifteen infants died 1 to 120 days postoperatively. Seven deaths resulted from intracranial bleeding, 3 from diffuse coagulopathy, and 1 from respiratory failure. The condition of patients with heart failure improved postoperatively, with the mean left atrium to aorta ratio reduced from 1.56 to 1.02 (p = 0.05). Respiratory function improved in 25 patients extubated by the third postoperative day. Late follow-up (one to five years) of the 51 survivors showed 1 late death. Seventeen survivors had roentgenographic evidence of bronchopulmonary dysplasia. Infants with bronchopulmonary dysplasia required longer postoperative ventilation (mean, 21.5 days compared with 4.75 days). Twenty-four infants were normal. Ligation of PDA in preterm infants has low intraoperative risk and improves the condition of those with heart and respiratory failure. Late follow-up showed good recovery of nearly two-thirds of the patients.

Intramyocardial Electrical and Metabolic Activity during Hypothermia and Potassium Cardioplegia

Hypothermic potassium cardioplegia is widely used to reduce myocardial metabolism as a means of myocardial protection. To investigate the efficacy of intramyocardial electrical activity as an indicator of myocardial metabolism, 12 dogs were placed on cardiopulmonary bypass and myocardial oxygen consumption, partial pressure of carbon dioxide (PCO2) in the coronary sinus, myocardial temperature, and intramyocardial and surface electrocardiograms were measured. The hearts were fibrillated and cooled to 15 degrees C. In Group 1 (6 dogs), potassium cardioplegia was given at 15 degrees C. In Group 2 (6 dogs), it was given at 25 degrees C. Maximum coronary sinus PCO2 and oxygen consumption occurred at 36 degrees C and gradually decreased, but there was still evidence of metabolic activity and intramyocardial electrical activity at 15 degrees C. When cardioplegia was given at 15 degrees C, all electrical activity ceased and there was a further significant reduction in metabolic activity (coronary sinus PCO2 and oxygen consumption). In Group 2 similar findings were found at 25 degrees C, and there was no further reduction in metabolic activity at 15 degrees C. These data indicate that: (1) myocardial metabolic activity is lowest when there is electrical quiescence as measured with an intramyocardial electrode; (2) potassium arrest and hypothermia are both necessary to achieve electrical quiescence; and (3) in the potassium-arrested heart, lowering temperature from 25 degrees to 15 degrees C does not result in a further reduction of metabolic activity.

The effect of autologous blood salvage techniques upon bank blood usage and the cost of routine coronary revascularization

Preservation of autologous blood during cardiac surgery may reduce the need for homologous blood transfusions. We reviewed our experience for patients undergoing primary coronary revascularization to determine the effect of the use of the Haemonetics Cell-Saver upon blood bank resources and upon the cost of operation. The quantity of homologous blood required by two groups of patients was compared. One group of 46 patients had operation prior to use of the Cell- Saver ; the other group of 31 patients was entered into Cell-Saver protocols. The mean number of homologous blood units transfused per patient fell strikingly (p < 0.0001) from 4.2 before to 0.5 after introduction of the Cell- Saver. Of the 31 patients in the Cell-Saver protocol, 71 % required no homologous blood while they received 2.5 units of autologous blood processed by the Cell-Saver. Related to this, the mean number of units prepared by typing and compatibility testing in anticipation of surgery fell from 10 units to five. The projected cost to the patient fell 23%. There were no adverse effects from the use of the Cell-Saver. We conclude that the use of the Cell-Saver is justified not only to reduce the potential risks of homologous blood transfusion, but also to reduce the strain upon blood bank resources and the patient cost of primary coronary revascularization.