Eli Milgalter

Partial Fontan: Advantages of an adjustable interatrial communication☆

Systemic venous hypertension after the Fontan procedure is a major cause of mortality and morbidity, accounting for 11 of 16 deaths in our series of 228 Fontan procedures. A partial Fontan with a residual atrial septal defect (ASD) would allow controlled right-to-left shunting to reduce venous pressure and improve cardiac output while maintaining a reduced but acceptable arterial oxygen saturation. This allows complete or graded closure of the ASD after the discontinuation of cardiopulmonary bypass in the operating room or at any time in the postoperative period by exposing the snare under local anesthesia. From 1987 to 1990, 36 patients undergoing the modified Fontan procedure had placement of an adjustable interatrial communication. Indications for placement of an adjustable ASD included increased pulmonary artery pressures, increased pulmonary vascular resistance, reactive airway disease, previously increased or unknown pulmonary vascular resistance, small pulmonary arteries, and borderline ventricular function. Fourteen patients had the adjustable ASD closed at the time of operation, 8 patients underwent narrowing, and 12 underwent closure of the ASD in the postoperative period. Eight patients were discharged with the ASD partially open, and 2 patients underwent delayed closure. The partial Fontan with an adjustable ASD may increase the safety of the Fontan procedure for high-risk groups such as those with increased pulmonary vascular resistance, pulmonary hypertension, and impaired left ventricular function and for infants, who tolerate venous hypertension poorly. The ability to adjust the ASD in stages depending on the hemodynamic response increases flexibility and safety.

Repair of truncus arteriosus in infancy

Improvements in myocardial protection, surgical technique, and postoperative care have decreased operative mortality for neonatal repair of truncus arteriosus. Primary repair of truncus arteriosus in infancy without prior pulmonary artery banding is currently the preferred approach. During the period from 1982 to December 1990, 32 patients under the age of 12 months underwent surgical correction of truncus arteriosus at UCLA. The average age was 3.5 months (range, 12 days to 12 months). Three patients had interrupted aortic arch. Early mortality for the entire group was 15.6% (5/32); for those older than 1 month early mortality was 7% (2/28). In the past 4 years, early mortality has decreased to 8.3% (2/24); both of these patients had interrupted aortic arch. Excluding patients with interrupted aortic arch, there were no early deaths in the last 22 patients (1986 to 1990). Late mortality overall was 7.4% (2/27). In a mean follow-up of 73 months (range, 40 to 110 months), 71% (5/7) of the survivors with Dacron porcine-valved conduits required conduit replacement secondary to obstruction. In a mean follow-up of 36 months (range, 1 to 89 months), only 14% (3/21) of the patients with homografts required replacement secondary to obstruction.

One-lung high-frequency ventilation in the management of traumatic tear of bronchus in a child.

An 8-yr-old child suffered traumatic bilateral pneumothoraces and a ruptured right main bronchus. Surgical repair of the bronchus was postponed for 18 h after a definite diagnosis was established due to severe hypoxemia and hypercarbia. Only left endobronchial high-frequency ventilation with muscle relaxation corrected this pulmonary dysfunction sufficiently to enable surgical intervention.

Normothemic Continuous Blood Cardioplegia Improves Electrophysiologic Recovery after Open Heart Surgery

Background Myocardial protection during open heart surgery is based on administration of oxygenated blood cardioplegia, the preferred temperature of which is still under debate. The current randomized study was designed to prospectively evaluate the quality of myocardial protection and the functional recovery of the heart with either normothermic (group N) or hypothermic (group H) oxygenated blood cardioplegia. Methods Under continuous electrocardiographic Holter monitoring, 42 patients were randomly scheduled to receive either normothermic (33.5 degrees C) or hypothermic (10 degrees C) cardioplegia solutions during coronary bypass grafting surgery. Blood samples for creatinine phosphokinase, creatinine phosphokinase‐MB, lactate, epinephrine, and norepinephrine were withdrawn during cardiopulmonary bypass via a coronary sinus cannula. Results Active cooling in group H on initiation of cardio‐pulmonary bypass was characterized by transition through ventricular fibrillation in 75% of patients, whereas in group N atrial fibrillation occurred in 65% of patients. On myocardial reperfusion, sinus rhythm spontaneously resumed in 95% of group N patients compared to 25% in group H (P = 0.0003). In the latter, 75% of patients developed ventricular fibrillation often followed by complete atrioventricular block, which necessitated temporary pacing for a mean duration of 168+/‐32 min. Both groups showed a similar incidence of intraventricular block and ST segment changes. However, the incidence of ventricular premature beats in the first 16 h after cardiopulmonary bypass was significantly greater in group H (P < 0.05), 20 +/‐26/h, compared to 3+/‐5/h in group N. Blood concentrations of lactate, creatinine phosphokinase, epinephrine, and norepinephrine increased gradually during the operation, but the differences between the groups were not significant. Conclusions The current prospective human study suggests that the increased susceptibility for ventricular fibrillation and dysrhythmia, and the delayed recovery of the conduction system after hypothermic myocardial protection, are related to temperature‐induced changes in vital cellular functions of the conduction tissue in the postischemic period. Both cardioplegic methods provide adequate myocardial protection but normothermic oxygenated blood cardioplegia may accelerate recovery of the heart after cardiopulmonary bypass.

Left Ventricular Free Wall Rupture as the Presenting Manifestation of Acute Myocardial Infarction in Diabetic Patients

We present 5 diabetic patients with acute myocardial infarction in whom left ventricular free wall rupture was the presenting manifestation. Echocardiography may be indicated in diabetic patients with acute myocardial infarction and in shock, prior to thrombolysis.

Aortic Valve Replacement Using a Continuous Suture Technique

Abstract The continuous suture technique has been proposed as an alternate method for aortic valve replacement (AVR). Advantages include a decreased ischemic and bypass time. Despite reports of a low incidence of perivalvular leak, wide use of the continuous suture technique has not been adopted. This report reviews our experience with the continuous suture technique. From January 1984 through November 1991, 181 consecutive patients underwent AVR using the continuous suture technique. The mean age was 61 years (range 6 to 88 years). Diagnoses included pure aortic stenosis (AS) in 41%, aortic insufficiency (Al) in 31%, and a combination of AS and Al in 28%. Fifty‐six patients underwent isolated AVR and 125 underwent AVR combined with other procedures. The overall early mortality was 5.5%. Early mortality for isolated AVR was 0% (0/56) and was 8.0% (10/125) for those undergoing concomitant procedures. Late mortality was 4.7% in a mean follow‐up of 30 months (range 1 to 86 months). The incidence of perivalvular leak was 2.3% (4/171 operative survivors). Perivalvular leak was mild in two, and moderate in two; none required reoperation. Perivalvular leak developed only in patients whose suture line was not reinforced with glutaraldehyde treated pericardium. The continuous suture technique is a quick and effective method for AVR and results in a low incidence of perivalvular leak.

Intraaortic Balloon Entrapment: A Complication of Balloon Perforation

A patient in whom perforation of a percutaneously inserted intraaortic balloon resulted in a clot formation inside the balloon is described. The balloon could not be withdrawn percutaneously and was lodged in the femoral artery. It was removed surgically, and the artery was repaired.

Dacron mesh wrapping to support the aneurysmally dilated or friable ascending aorta

A technique of supporting the aneurysmally dilated or friable ascending aorta using a fine Dacron mesh is described. In patients with aneurysmal dilatation of the ascending aorta, longitudinal resection of a portion of the aneurysm combined with wrapping can avoid replacement with a synthetic graft. The Dacron mesh, because of its transparency and ability to stretch, allows a more accurate fit over the aorta, avoids hematoma formation, provides visualization of suture lines after wrapping, and facilitates proximal vein graft anastomoses for combined aortocoronary bypass.

Open heart operation after pneumonectomy

A coronary artery bypass operation was performed successfully on a 70-year-old patient who had undergone left pneumonectomy 40 years earlier. This case, together with a search of the literature and a mail survey among 118 cardiothoracic surgeons worldwide, yielded data on 27 such patients for review. Two patients died perioperatively. Three patients had pneumothorax, and 1 patient had recurrent pleural effusion. Difficulty in exposing the circumflex marginal branches was reported in 2 patients after left pneumonectomy. We conclude that with attention to the specific features of the preoperative, intraoperative, and postoperative management, open heart procedures can be performed on patients after pneumonectomy with acceptable operative mortality and morbidity.

Use of a pericardial patch to bridge the conduction tissue during tricuspid valve replacement

Tricuspid valve replacement carries a risk of causing complete heart block. To reduce this risk, a technique was developed to bridge the conduction system during prosthetic valve insertion in the tricuspid position. This technique, in which a pericardial patch is used to bridge the triangle of Koch, was performed successfully in 4 patients who underwent tricuspid valve replacement for Ebsteins anomaly of the tricuspid valve.