Douglas A. Murphy

Concomitant carotid and coronary artery reconstruction.

Data are presented on 68 patients who underwent concomitant carotid endarterectomy (CE) and coronary artery bypass surgery (CAB) at Emory University Hospital from January 1974 to February 1981. This group is then compared with a randomly selected, matched population without known carotid disease who underwent CAB alone. Asymptomatic bruit was the reason for investigation in 40 patients (59%); another 23 patients (34%) experienced transient cerebral ischemic attacks (TIAs); and five patients (7%) had TIA and prior stroke. Carotid stenoses (>75% luminal narrowing) were demonstrated as follows: isolated left, 24 patients; isolated right, 27 patients; and bilateral lesions, 16 patients. One patient had innominate artery stenosis. Associated total occlusion of one or both vertebral arteries was demonstrated in six patients. Ninety-seven per cent of patients had disabling angina pectoris prior to operation; the angina was unstable in 57%, 15% had congestive heart failure, and 54% had had at least one prior myocardial infarction (MI). Single-vessel coronary disease was present in 12.5% of patients, double in 37.5%, triple in 41.1%, and left main stenosis in 9%; 43% of patients had abnormal ventricular contractility. CE was performed on 67 patients (36 left and 31 right); aortocarotid bypass was performed on one. The CE procedures were performed immediately prior to the sternotomy for CAB under the same anesthesia. CAB consisted of single bypass in eight patients (11.8%); double in 16 patients (23.5%); triple in 22 patients (32.4%); and quadruple or more in 22 patients (32.4%) (mean = 2.9 grafts per patient). There was no hospital mortality. Perioperative MI occurred in 2.0% and stroke with residual deficit in 1.3%. Cumulative survival is 98.5% at two years. Sixty-three patients (92%) reported improvement or elimination of anginal symptoms after operation. Kehospitalization for stroke was necessary in 3.7% patients. Postoperative activity levels are: self-care only, 3.9%; normal daily activity only, 17.6%; moderate exercise capability, 45%; and vigorous exercise capability, 33%. Comparison was made with a group of 84 randomly selected patients who underwent CAB alone during the same time interval. Data revealed no significant difference between the groups regarding sex, angina subset, ventricular function, coronary anatomy, vessels grafted, perioperative stroke or MI, mortality, or postoperative activity capability. Older age (59.8 vs. 55.6, p < 0.01) and less complete coronary revascularization possible (66 vs. 84%, p < 0.05) in the CE-CAB group were the only significant differences. Carotid stenosis co-existing in patients requiring CAB should be concomitantly corrected with the same risk and results expected from, CAB alone.

An echo-dense mass in the pericardial space as a sign of left ventricular free wall rupture during acute myocardial infarction

Abstract Echocardiography has widespread popularity for diagnosis of the complications of acute myocardial infarction (AMI). Only recently has it been used to evaluate patients suspected of having cardiac rupture. 1–4 A patient is described who presented with lateral wall AMI complicated by cardiac rupture. An echocardiogram documented this complication and prompted immediate surgical repair.

Major histocompatibility complex class I and class II expression by myocytes in cardiac biopsies posttransplantation.

A total of 85 cardiac biopsies from patients 23–265 days posttransplant were studied for the correlation of the rejection grade score with the level of major histocompatibility complex (MHC) class I and class II expression on cardiac myocytes and endothelial cells, the quantitative level of leukocytic infiltrate, and the immunophenotype of the leukocytes. Results indicate a lack of absolute correlation between rejection grade scores and levels of MHC antigen expression. Further, a lack of absolute correlation was also seen with quantitation of leukocytic infiltrates and relative levels of MHC antigen expression. Of great interest was our preliminary finding that as early as 4 weeks prior to a rejection episode scored by routine histological criteria as grade 4, cardiac biopsy from the patient demonstrated high levels of MHC class I and class II expression. Similar increases of MHC antigen expression prior to an increase in histological rejection score grades were also noted in serial biopsies of 2 other patients. These data suggest that it may be quite useful to examine levels of MHC antigens on cardiac biopsies posttransplantation as an additional parameter for monitoring of cardiac rejection episodes.

The Expanding Role of Endoscopic Robotics in Mitral Valve Surgery: 1,257 Consecutive Procedures

BACKGROUNDnThe role of robotic instruments in mitral valve (MV) surgery continues to evolve. The purpose of this study was to assess the safety, efficacy, and scope of MV surgery using a lateral endoscopic approach with robotics (LEAR) technique.nnnMETHODSnFrom 2006 to 2013, a dedicated LEAR team performed 1,257 consecutive isolated MV procedures with or without tricuspid valve repair or atrial ablation. The procedures were performed robotically through five right-side chest ports with femoral artery or ascending aortic perfusion and balloon occlusion. Operative videos and data were recorded on all procedures and reviewed retrospectively.nnnRESULTSnThe mean age of all patients was 59.3 ± 20.5 years, and 8.4% (n = 105) had previous cardiac surgery. The MV repair was performed in 1,167 patients (93%). The MV replacement was performed in 88 patients (7%), and paravalvular leak repair in 2 patients. Concomitant atrial ablation was performed in 226 patients (18%), and tricuspid valve repair in 138 patients (11%). Operative mortality occurred in 11 patients (0.9%) and stroke in 9 patients (0.7%). Predischarge echocardiograms demonstrated mild or less mitral regurgitation in 98.3% of MV repair patients. At mean follow-up of 50 ± 26 months, 44 patients (3.8%) required MV reoperation. Application of the LEAR technique to all institutional isolated MV procedures increased from 46% in the first year to more than 90% in the last 3 years.nnnCONCLUSIONSnMitral valve repair or replacement, including concomitant procedures, can be performed safely and effectively using the LEAR technique. With a dedicated robotic team, the vast majority of patients with MV disorders, either isolated or with concomitant problems, can be treated using the LEAR technique.

Comparison of coronary artery bypass surgery and percutaneous transluminal coronary angioplasty including surgery for failed angioplasty

Selection and treatment of patients with ischemic heart disease is presently undergoing an evolutionary trend. Percutaneous transluminal coronary angioplasty (PTCA) has been recommended as the initial procedure for many patients with coronary artery disease and has thus redefined candidates for coronary artery bypass surgery. During our first years of experience with percutaneous angioplasty, 339 patients underwent the procedure and were compared with 338 patients who underwent isolated coronary artery bypass surgery. Patients who underwent PTCA had a shorter duration of angina and a lower number of prior myocardial infarctions and were found to have better left ventricular function (p less than 0.01). PTCA was considered initially successful in 87% (295 of 339) of patients. The most common finding at operation in those with failed angioplasty who underwent urgent or emergency revascularization was dissection of atheromatous plaque. Although the cumulative frequency of new Q waves in the entire 18-month angioplasty series was low (2.7%), the incidence was high (18%) in those with angioplasty failure and subsequent operation (N = 20) and significantly greater than in patients who had elective coronary artery bypass surgery (3.6%). Use of inotropic agents and lidocaine for ventricular arrhythmias was significantly higher in patients with unsuccessful PTCA who required operation than in those who underwent elective bypass surgery (10% vs 3% and 10% vs 1.5%, respectively; p less than 0.01). In an analysis of our entire experience between October 1980 and June 1982, 777 patients who had PTCA and 2068 patients who underwent coronary artery bypass surgery were analyzed for differences in clinical complications and early outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Distal Coronary Artery Dissection Following Percutaneous Transluminal Coronary Angioplasty

The most common cause of acute myocardial ischemia following percutaneous transluminal coronary angioplasty is coronary dissection, which characteristically remains localized to the site of balloon dilation. In this article, however, we report on 4 patients in whom percutaneous transluminal coronary angioplasty was complicated by coronary artery dissection extending distally beyond the site of anticipated vein graft anastomosis. Intraoperative diagnosis of distal coronary dissection is suggested by a characteristic appearance of the artery and confirmed by the finding of true and false lumens at the time of coronary arteriotomy. Successful revascularization is achieved by anastomosis of a vein graft to the true lumen with reapproximation of the dissected arterial layers. Proximal coronary artery ligation in this setting is unnecessary.

Mitral valve repair using robotic technology: Safe, effective, and durable.

The most recent American College of Cardiology/American Heart Association heart valve guidelines recommend that prompt surgical correction of severe degenerative mitral valve regurgitation, ideally mitral valve repair, should be performed to decrease the risks of long-term mortality and heart failure risks associated with this condition. Mitral valve repair performed using a minimally invasive robotic approach can now be successfully carried out in nearly all cases of degenerative disease with very low risks of stroke or death. Experienced groups have further shown specific advantages of robotic mitral valve repair compared with conventional approaches, including reduced blood loss, lower risks of infection and atrial fibrillation, shorter hospital length of stay, quicker return to normal activities, and a superior cosmetic result. Herein, we discuss the current status of robotic mitral valve repair including indications, technical advances, safety, effectiveness, and durability.

Delayed Closure of the Median Sternotomy Incision

Attempts to close a median sternotomy incision in the patient with profound cardiac or pulmonary dysfunction following a cardiac surgical procedure can result in severe hemodynamic deterioration. Delayed sternal closure in this setting may be a lifesaving technique. A method is described for delayed sternal closure that employs a temporary impermeable rubber patch sutured to the presternal fascia.

Hemodynamic deterioration after coronary angioplasty in the presence of previous left ventricular infarction

This prospective-controlled study did not reveal any additional protective effect of 500 ml of dextran-40 when combined with other drugs in preventing acute coronary artery occlusion during PTCA. Several factors may have influenced this result. First, all study patients were treated with antiplatelet drugs before and after PTCA. This may have masked any beneficial effect contributed by dextran6 Second, the protocol for dextran administration was based on the common cardiac laboratory practice of infusing 500 ml of dextran-40 immediately before and during PTCA. The maximal effect of dextran on platelet inhibition, however, may occur as long as 4 to 6 hours after administration.3*4 The infusion-dilatation interval under this protocol may have been too short for full dextran-mediated platelet inhibition to take place. In addition, the angiographic studies performed do not allow discrimination between different causes for coronary occlusion, only some of which might be amenable to a dextran effect.

Successful Robotic Excision and Early Chemotherapy for Primary Cardiac Lymphoma

We present a 67-year-old patient who underwent robotic excision of a mobile left ventricular mass found incidentally on echocardiography. Intraoperative findings revealed a pedunculated mass infiltrating the interventricular septum, and the results of pathologic examination of the frozen section were consistent with malignancy. The final pathologic examination showed a diffuse large B-cell lymphoma, and early chemotherapy was initiated.xa0Follow-up cardiac positron emission tomography/computed tomography showed completely normal myocardium without evidence of malignancy. The lateral endoscopic robotic approach across the mitral valve permitted optimal tumor visualization and early chemotherapy initiation without concern for cardiac rupture or related adverse events.