Bernard S. Goldman

Permanent Cardiac Pacing After Open Heart Surgery: Congenital Heart Disease

A retrospective review of 6,004 patients who underwent open repair of congenital heart defects revealed that 132 patients (2.2%) required permanent cardiac pacing postoperative/y. The indications for pacing were early atrioventricular (AV) block in 55%, late onset AV block in 31%, and sick sinus syndrome in 34%. A ventricular septal defect (VSD) was the most common congenital anomaly present alone or in association with other lesions in 67% of the patients. Atrial surgery accounted for 21% of the patients requiring pacing. Ten‐year patient survival was found to be 66% (± 6%). Thirty‐five percent of the deaths were sudden and unexpected, presumably due to an arrhythmia. Reoperation for pacing system failure has occurred too frequently (12% per year). The most common causes for reoperation were battery failure (44%) and exit block (25%).

Aortic valvoplasty for traumatic aortic insufficiency : a 2-year follow-up

A 23-year-old man sustained acute rupture of an aortic valve cusp in a motorcycle accident. We repaired the valve using an autologous pericardial patch. A 2-year follow-up two-dimensional echocardiogram and Doppler study show completely normal appearance and function.

Functional and Metabolic Effects of Anoxic Cardiac Arrest

Abstract Myocardial changes were studied in 12 dogs and 5 patients to determine whether anoxic, normothermic cardiac arrest, a simple, effective adjunct in open-heart surgery, is detrimental to cardiac function. After 30 minutes of aortic occlusion the dogs showed uniform depression of left ventricular function with profound metabolic acidosis and elevation of lactate of the coronary sinus blood. Five patients who had 21 to 45 minutes of anoxic cardioplegia also showed marked respiratory acidosis, elevation of the lactate/pyruvate ratio, and a progressive rise in lactate of the coronary sinus blood. The effects of anoxia on the human heart are comparable to those observed in the dog. We believe that anoxic cardioplegia of 45 minutes is tolerated by patients but that coronary perfusion should be employed after that length of time.

Assessment of Mitral and Tricuspid Competence after Valvuloplasty

Abstract An accurate intraoperative assessment of valvular competence is essential to evaluate the results of valvuloplasty for the mitral or tricuspid valve. A simple, reliable, and reproducible technique employing a standard cardioplegia apparatus is described. Cold Ringers lactate solution is infused through a small apical ventricular vent from the cardioplegia line at a controlled pressure to assess the competence of the mitral or tricuspid valve before and after valvuloplasty.

DDI Pacing: Indications, Expectations, and Follow-Up

The DDI mode of pacing that permits noncompetitive atrioventricular sequential bradycardia support was chosen in 65 of 480 (14%) patients selected for dual chamber pacing between February 1985 and March 1990. All patients were implanted with Pacesetter 283 or 285 pulse generators and programmed to DDI. The indications for pacing were sick sinus syndrome (n = 52), combined sinus node dysfunction and AV block (n = 13). Forty‐two of these patients had a history of paroxysmal atrial arrhythmias. All patients received passive fixation atrial and ventricular leads. Follow‐up thereafter was performed predischarge, and at 6 weeks, 3 and 6 months after discharge. The duration of follow‐up ranged from 1‐61 months (mean 31 months). Fifty‐four of 65 (83%) patients chosen for DDI remain programmed in the DDI mode. Three patients were reprogrammed to VVI and eight to DDD. During the course of follow‐up, six patients presented with effective VVI pacing with consistent ventriculoatrial conduction that was appropriately sensed by the atrial circuit with atrial output inhibition. A further four patients presented with “functional undersensing” due to ventricular blanking period (VBP) characteristics in these pulse generators and in this mode. Functional undersensing was eliminated in all but one patient by reprogramming the VBP to 13 msec with no subsequent episodes of provoked crosstalk inhibition. Effective VVI pacing was observed in patients with AV block during times of sinus acceleration. While DDI mode is an effective form of pacing, permitting non‐competitive atrioventricular sequential pacing, potential limitations include: effective VVI pacing during intact ventriculoatrial conduction, functional undersensing when long VBP are programmed, and effective VI pacing with sinus node acceleration during AV block.

Computer‐Assisted Reporting System for the Follow‐up of Patients with Cardiac Pacemakers

The implantation of large numbers of permanent cardiac pacemakers carries with it the responsibility for continual reassessment of all aspects of patient management. Experience with more than 4,000 pacemaker implants and replacements since 3963 has led to the development of a comprehensive computer‐assisted data collection, management, and reporting system for the follow‐up of patients with cardiac pacemakers. Over a seven‐year period, data forms have been developed for the detailed documentation of pre‐operative, intraoperative and follow‐up information. These were designed in the form of checklists suitable for direct computer entry using mark‐sense document readers. Special emphasis has been placed on pre‐operative indications, selection of appropriate pacing systems, reliable follow‐up methodology, and monitoring the performance of various pulse‐generators. This system makes possible the rapid computer production of hospital records and reports to involved physicians and can be used to schedule follow‐up assessments as required. The information also can be used for hospital statistics, billing, research, and pacemaker registration at the provincial, slate or federal level. Experience has shown that a computer‐assisted methodology is the only practical means of providing adequate follow‐up for a large group of patients. In addition, direct access to relevant information helps to create an environment in which essential research can be carried out in the face of demanding clinical practice.

A Technique for Selective Graft Perfusion During Aortocoronary Bypass

A technique is described that provides early reperfusion of acutely ischemic myocardium during the construction of saphenous vein bypass grafts to the coronary arteries. Selective vein graft perfusion provides early and appropriate cooling of the most ischemic zones identified by either electrocardiographic changes or intramyocardial temperature probes and allows warm blood reperfusion during construction of proximal anastomoses. The technique may be applicable to patients who present with acute ischemia and evolving infarction, failed angioplasty, or left main coronary artery stenosis.

Initial Experience with Universal Pacemakers

Thirty‐five patients were implanted with the Sequicor DDD pacemaker between September l, 1981 and March 1, 1982. The mean age was 61.7years (range, 17–88). According to their ECGs, the patients fell into two distinct groups—those with A‐V block and those with sick sinus syndrome. Our initial experience has indicated an excellent eleo tronic component furtction (except for l discrepant reed switch); high battery drain of the Sequicor; complications similar to those seen with DVI or VVI pacing; and an increase in the hemodynamic benefits resulting from DDD as compared to DVI or VVI pacing in 70% of patients.

Comprehensive Evaluation of Ventricular Function During Physiological Pacing

To assess the effects of the various modes of physiological pacing on left ventricular volume and hemodynamics, we studied 12 pts (age 52 ± 4 yrs) who had intramyocardial tantalum markers implanted at the time of coronary bypass surgery: Left ventricular (LV) end-diastolic volume (EDV) and ejection fraction (EF) were determined from cinefluoroscopic tantalum marker ventriculograms, validated with contrast angiography.

Pericardial Graft for Intraoperative Balloon Pump Insertion

A technique that permits rapid insertion of an intraaortic balloon pump to support patients who cannot be successfully weaned from cardiopulmonary bypass is described. A pericardial patch is obtained while the sternum is still open, and is sutured to a common femoral arteriotomy. A 6-0 Prolene mattress stitch is inserted at the heel and continued along the sides. The ends are tied at the toe, and the same suture is used to construct a tube of pericardium over the balloon catheter. A single heavy silk suture is placed around the pericardial graft to prevent bleeding. The technique helps prevent thrombus and avoids infectious complications. It reduces the incidence of vascular complications and makes use of the Fogarty catheter after balloon removal unnecessary. We have used the method in 9 patients since November, 1979, without problems.