George A. Liebler

Use of the BioMedicus Centrifugal Pump in Traumatic Tears of the Thoracic Aorta

Traumatic blunt thoracic aortic injury is a clinical entity of increasing incidence. After the diagnosis of traumatic tear of the aorta is made, there is some controversy over whether the aorta should be repaired using cardiopulmonary bypass, a heparinized shunt, or cross-clamping and graft interposition without a shunt or bypass. At Allegheny General Hospital, 19 patients were treated for traumatic tears of the thoracic aorta between July 1, 1977, and June 30, 1983. They can be divided into two groups: Group 1 (July 1, 1977, through October 31, 1981), in which no shunt or bypass or only a heparinized shunt was used, and Group 2 (November 1, 1981, through June 30, 1983), in which left atrium-femoral artery bypass was performed using a BioMedicus heparinless pump and tubing. Among the 10 patients in Group 1, 4 died and 2 had paraplegia postoperatively. Among the 9 patients in Group 2, 1 died and none experienced paraplegia following operation. We believe that the BioMedicus centrifugal pump is a simple, safe means of perfusing the lower body, kidneys, and spinal column without necessitating heparinization in a patient with multiple injuries or the placement of a cumbersome heparinized shunt. Because of the simplicity and the reliability demonstrated, this pump should be considered for use in all patients with traumatic tears of the thoracic aorta.

Paced skeletal muscle for dynamic cardiomyoplasty

Four patients, each with a history of myocardial infarction and diffuse coronary artery disease, underwent application of left latissimus dorsi (LD) muscle with intact neurovascular bundle to the anterolateral wall of the left ventricle. The muscle was conditioned over a six-week period subsequent to operation in 3 patients and was conditioned preoperatively with a burst stimulus in the fourth. Biopsy specimens confirm the experimental data that human skeletal muscle can be electrically conditioned over a six- to ten-week period to contain mainly fatigue-resistant type I fibers. All patients survived the procedure, and 3 showed improvement secondary to aneurysmectomy. In Patient 1, a modified resection was performed, and at 28 months after operation, at the 75-W level of exercise, the ejection fraction was 54% paced versus 45% nonpaced. In Patient 2, at 12 months, the ejection fraction at rest was 44% paced versus 30% nonpaced. Doppler echo studies confirmed the presence of the flap and its function in the paced and nonpaced mode. The third patient died of a sudden ventricular arrhythmia 2 months following operation. An infected, nonfunctioning, degenerated flap was found at autopsy. Patient 4 did not have an aneurysm. She received a bypass graft to the right coronary artery and underwent cardiomyopexy in an attempt to relieve medically refractory incapacitating chronic congestive heart failure. Ten months postoperatively, ejection fraction at rest was 33% paced versus 25% nonpaced. Constrictive myopathy has not been encountered in any of these patients.

The carcinoembryonic antigen assay in bronchogenic carcinoma

Pretreatment levels of plasma carcinoembryonic antigen (CEA) were determined for a series of patients with bronchogenic carcinoma and for a series of patients with benign pulmonary disease. These data were analyzed to determine the diagnostic and prognostic value of the CEA radioimmunoassay in bronchogenic carcinoma. CEA plasma values in patients with benign pulmonary disease indicate that the level of discrimination between positive and negative tests for bronchogenic carcinoma should be at least 5.0 ng/ml. Half the patients with bronchogenic carcinoma in this study had CEA plasma values less than 5.0 ng/ml. The data also indicate that the CEA test does not correlate well with patient survival or stage of disease at time of diagnosis, and that the CEA test frequently fails to identify patients with extensive metastatic disease. It is concluded that the pretherapy plasma CEA level will not be of value as a diagnostic or prognostic test in the management of a significant number of patients with bronchogenic carcinoma.

Mechanical Support of the Failing Heart

Mechanical ventricular assist with a centrifugal pump with or without anticoagulation for an extended period has been used in 41 patients with postcardiotomy ventricular failure. Left ventricular, right ventricular, and biventricular assist were required. The efficacy and safety of mechanical ventricular assist have been documented. Marked improvement in survival has been observed in the more recent part of this series, and is attributed to earlier employment of the assist device, maintenance of better flow rates near physiological levels, and use of biventricular assist to provide effective circulatory support. Mechanical ventricular assist is easy to use, and the conversion from ordinary cardiopulmonary bypass is also easy. Therefore, mechanical assist provides a very effective means of temporary circulatory assist.

Paced latissimus dorsi used for dynamic cardiomyoplasty of left ventricular aneurysms.

Two patients are described, each with a large left ventricular aneurysm and severe coronary artery disease, and each with an ejection fraction lower than 30% and in congestive heart failure. In both, the left latissimus dorsi (LD) muscle was used in the repair of the ventricular aneurysm because preoperative studies demonstrated that there was concomitant coronary artery disease, and there was a strong suggestion that resection of the entire aneurysm would seriously compromise the residual ventricular capacity. One patient had an 18-year history of coronary occlusion with two infarctions. A large, calcified ventricular aneurysm developed, and despite vigorous medical treatment, intractable congestive heart failure and angina persisted. The diffuse coronary artery disease made this patient a poor candidate for bypass grafting. The other patient sustained an acute myocardial infarction 5 months prior to operation. The left anterior descending coronary artery was totally occluded, and a large apical aneurysm developed along with an akinetic anterior wall and septum. After his heart attack, the patient had progressive dyspnea on exertion. Following operation in both patients, the transpositioned LD, then a component in the repair of the left ventricular wall, was electrically trained to synchronously contract with each systole, driven by a standard dual-chamber cardiac pacemaker. Steady improvement and a return to normal activities were observed in both patients. There was an indication of improved ejection fraction with synchronous contraction of the skeletal muscle.

Infectious Complications and Cost-Effectiveness of Open Resuscitation in the Surgical Intensive Care Unit after Cardiac Surgery

From July, 1982, to May, 1984, 2,412 patients underwent cardiac surgery. Open resuscitation through a midline sternotomy was performed in the surgical intensive care unit (SICU) 88 times in 64 patients one minute to 10 days after admission. There were 49 initial survivors; 31 patients had primary closure in the SICU (Group 1), and 18 patients had delayed closure (Group 2). In Group 1 there was 1 death. Wound infection developed in 2 of the 30 survivors--Escherichia coli in 1 and Staphylococcus epidermidis in 1. The latter required subsequent debridement. In Group 2 there were 8 survivors and no wound infections. Fifteen patients could not be resuscitated because of ventricular arrhythmia (13%), asystole (33%), cardiogenic shock (47%), and tamponade (7%). Only 2 of 38 patients, or 5%, experienced wound infections. This study demonstrates that open resuscitation in the SICU is a safe, rapid, and cost-effective procedure that will allow earlier intervention, diagnosis, and treatment. In no instance was death attributed to wound infection, and at our institution, this method resulted in cost savings of more than

Twenty-five-year review of the Magovern-Cromie sutureless aortic valve

1,000 per patient.

Carotid Sinus Syndrome: New Surgical Considerations:

We reviewed 25 years (4,798 patient-years) of aortic valve replacement with the Magovern-Cromie sutureless valve. Operative mortality was 11% for isolated aortic valve replacement and 15% for aortic valve replacement with concomitant cardiac procedures. Since 1981, operative mortality has declined to 4.9%. Valve-related morbidity was in the lower expected ranges for prosthetic aortic valves: ball variance, 0.3%/patient-year; paraprosthetic leak, 0.41%/patient-year; valve endocarditis, 0.43%/patient-year; valve thrombosis, 0.04%/patient-year; and embolic events, 3.95%/patient-year. The incidence of aortic valve reoperation was 0.76%/patient-year. The 5-year, 10-year, and 20-year probability of survival corrected for normal mortality was 77%, 64%, and 52% for all discharged patients. This review confirms the Magovern-Cromie valve to be a safe, durable, and efficient prosthetic valve.

Traumatic Aortic Transection: Repair Using Left Atrial to Femoral Bypass

1. Direct surgical denervation of the carotid sinus would appear to offer the best long-term results for carotid sinus syncope. 2. Carotid sinus denervation should be done under temporary cardiac pacing for safety and for completeness of denervation. 3. Arteriography is indicated to eliminate those cases of cerebral vascular insufficiency that might mimic carotid sinus syndrome. Credit must be given to Dr. R. Hughes, Clearfield, Pa., who recognized this diagnosis and referred the patient for therapy.

Is percutaneous insertion of the intra-aortic balloon pump through the femoral artery the safest technique?

Traumatic aortic transaction is a life‐threatening surgical emergency. Therapy must be directed at rapid repair and prevention of postoperative complications, the most serious being paraplegia. Controversy over the optimal method of repair exists‐specifically whether the use of a shunt modifies the outcome. Our series of 17 patients using left atrial to femoral bypass with the Biomedicus pump will be discussed. Preoperative preparation and operative technique will be outlined. Mortality in this series was 18%, the incidence of paraplegia was 0.