George M. Palatianos

Clinical Experience With Subxiphoid Drainage of Pericardial Effusions

To assess the effectiveness of subxiphoid pericardial tube drainage for treatment of pericardial effusion, we reviewed 41 consecutive patients who underwent this procedure during a 14-year period. The patients ranged in age from 7 months to 75 years. All were symptomatic preoperatively. The diagnosis of pericardial effusion was confirmed by echocardiogram in all but 2 patients. Eight patients had acute pericardial tamponade. Subxiphoid pericardial drainage was performed under general (n = 35) or local anesthesia (n = 6). A portion of the anterior pericardium was excised in each patient. There were no perioperative deaths. Thirty-day mortality was 19.5%; there were five late deaths. All deaths were unrelated to pericardial effusion or to the operation. One patient had recurrent effusion requiring pericardiocentesis on the 21st postoperative day. He died five days later of extensive lymphoma. Twenty-eight patients were followed from 1 month to 10 years; mean follow-up was 31.5 months. None developed recurrent effusion or pericardial constriction. We conclude that subxiphoid pericardial drainage is effective for treatment of pericardial effusion.

Comparative thrombogenicity of pacemaker leads.

To evaluate the throm bogenicity of transvenous silicone and polyurethane pacemaker leads, 9 of 12 anesthetized Yorkshire pigs (27–32 kg) were implanted with silicone (n = 5) or polyurethane (n = 4) pacemaker leads via a femoral vein. The remaining three pigs served as controls. All 12 pigs were injected with autologous indium‐111 labeled platelets (300–420 μCi) 24 hours before anesthesia induction. The pigs were monitored for 3 hours under a gamma camera. Radioactivity in blood and lead segments was measured with a gamma counter. Platelet deposits were denser on silicone leads (441.58 ± 915.0 to 2.19 ± 2.07) than on polyurethane leads (1.21 ± 1.33 to 0.27 ± 0.14) (P > 0.05). Denser platelet deposits were detected at the tip of all leads. Density of platelet deposits declined from tip to distal segments in silicone leads. The percentage of injected platelet radioactivity in the lungs of pigs with either silastic leads (12.9 ± 2.3%) or polyurethane leads (10.1 ± 2.2%) was higher than in the controls (4.6 ± 0.5%) (P < 0.05). This difference indicates thrombus formation and embolization in the lungs early after lead implantation. Thrombogenicity of polyurethane leads may be lower than that of silicone leads.

A prospective, double-blind study on the efficacy of the bioline surface-heparinized extracorporeal perfusion circuit

BACKGROUND We evaluated the newly introduced Bioline heparin coating and tested the hypothesis that surface heparinization limited to the oxygenator and the arterial filter will ameliorate systemic inflammation and preserve platelets during cardiopulmonary bypass (CPB). METHODS In a prospective double-blind study, 159 patients underwent coronary revascularization using closed-system CPB with systemic heparinization, mild hypothermia (33 degrees C), a hollow-fiber oxygenator, and an arterial filter. The patients were randomly divided in three groups. In group A (controls, n = 51), surface heparinization was not used. In group B (n = 52), the extracorporeal circuits were totally surface-heparinized with Bioline coating. In group C (n = 56), surface heparinization was limited to oxygenator and arterial filter. RESULTS No significant difference was noted in patient characteristics and operative data between groups. Operative (30-day) mortality was zero. Platelet counts dropped by 12.3% of pre-CPB value among controls at 15 minutes of CPB, but were preserved in groups B and C throughout perfusion (p = 0.0127). Platelet factor 4, plasmin-antiplasmin levels, and tumor necrosis factor-alpha increased more in controls during CPB than in groups B or C (p = 0.0443, p = 0.0238 and p = 0.0154 respectively). Beta-thromboglobulin, fibrinopeptide-A, prothrombin fragments 1 + 2, factor XIIa levels, bleeding times, blood loss, and transfusion requirements were similar between groups. Intensive care unit stay was shorter in groups B and C than in controls (p = 0.037). CONCLUSIONS Surface heparinization with Bioline coating preserves platelets, ameliorates the inflammatory response and is associated with a reduced fibrinolytic activity during CPB. Surface heparinization limited to the oxygenator and the arterial filter had similar results as totally surface-heparinized circuits.

Comparison of Long-Term Results of Carpentier-Edwards and Hancock Bioprosthetic Valves

The long-term survival following valve replacement with Carpentier-Edwards or Hancock bioprostheses was compared between the two valve models and between the two groups totaling 407 patients who were discharged after valve replacement beginning in 1974. The two groups of patients were treated in a nonrandomized fashion. The actuarial survival for 299 patients with Carpentier-Edwards valves was 94 +/- 1.5% (+/- standard error) and 93 +/- 1.7% after 5 and 8 years of follow-up, respectively. Comparable figures for 108 patients undergoing valve replacement with Hancock valves were 89 +/- 3.0% and 83 +/- 3.7%, respectively (p = not significant [NS]). The probability of freedom from death and valve removal after 5 and 8 years of follow-up was 91 +/- 1.8% and 79 +/- 4.6%, respectively, with the Carpentier-Edwards valve and 84 +/- 3.5% and 75 +/- 4.3%, respectively, with the Hancock valve (p = NS). An accelerated rate of attrition for both valves was observed in the mitral position. There were no significant differences in actuarial survival between the two valves in the mitral or the aortic position or in the incidence of major valve-related complications.

Sequential internal mammary artery grafts for coronary artery bypass

From 1985 to 1990, 145 patients underwent isolated coronary artery bypass with one (n = 128) or both (n = 17) internal mammary arteries (IMAs) used as sequential bypass grafts. All but 2 patients had angina pectoris preoperatively. A total of 162 sequential IMA grafts were constructed bypassing two (n = 152) or three (n = 10) coronary artery sites as in situ (n = 132) or free (n = 30) grafts. In 12 patients, one IMA was used as a nonsequential graft. Thirty-day mortality was 2.8% (n = 4 patients). Perioperative myocardial infarction occurred in 1 patient (0.7%). Only two sequential IMA grafts failed. Both were used to bypass coronary arteries 1.00 mm in diameter. Mean follow-up was 31 months (range, 6 months to 4.2 years). There were three late deaths. Of 136 survivors followed-up, 121 (89%) were free of angina. Postoperative rotational thallium 201 tomography was done in 73 patients. Myocardial ischemia was detected in 11 diabetic patients (15.1%), but corresponded to a sequential IMA graft in 4 (5.5%) and to nonsequential and venous grafts in 10 patients (13.7%). Coronary revascularization with sequential IMA grafts was safe and effective.

The Automatic Implantable Cardioverter Defibrillator: Results, Observations, and Comments

The automatic implantable cardioverter‐defibrillator (AICD) is a device of proven efficacy in life‐threatening ventricular tachycardia and fibrillation. Initial experience with the AICD at the University of Miami consists of 21 patients with recurrent ventricular dysrhythmias for a total follow‐up of 3–35 months (mean 19). There were two deaths in the series, one nonarrhythmic and one arrhythmic, at the fifth and tenth postoperative months respectively. There were five complications requiring reoperation in three patients. Pacemakers were required in four patients with the AICD and resulted in interesting observations. Our data concur with previously published reports of improved survival in selected patients.

The implantable cardioverter-defibrillator: Clinical results

To evaluate the effectiveness of the automatic implantable cardioverter‐defibrillator (AICD), a 7‐year experience, from 1983–1990, was reviewed. A total of 111 patients received an AICD device. Their ages ranged between 8 and 83 years. Mean age was 63.9 years. There were 91 men and 20 women. Eighty of the patients received the AICD following an out‐of‐hospital cardiac arrest, white 32 were suffering from intermittent symptomatic ventricular tachycardia. The underlying etiology in 97 patients (87%) was ischemic coronary artery disease, in 11 patients (10%) dilated cardiomyopathy, and in 3 patients (3%) idiopathic ventricular fibrillation. Mean ejection fraction was 33.2%. Implantation of the AICD was performed via a left thoracotomy in 39 patients, median sternotomy in 49 patients and subxiphoidsubcostal approach in 23 patients. In‐hospital mortality occurred in one patient who suffered an acute myocardial infarction 4 hours postoperatively. Out‐of‐hospital mortality was observed in 19 patients. There were two arrhythmic deaths. Follow‐up was available for 107 patients. Mean follow‐up was 33.1 months. Sixty‐six patients (62%) had AICD shocks. The initial appropriate shocks occurred during the first postimplantation year in 91% of the patients. In 53 of the survivors, initial AICD shocks took place within 4.4 ± 4.7 months from implantation. Thirteen of the 20 patients who died had received appropriate AICD shocks. In these patients, the time between implantation and first shock was 2.7 ± 3.6 months whereas the time between implantation and death was 11.3 ± 10.3 months (NS). We conclude that the AICD is effective in converting ventricular tachyarrhythmias and prolongs survival.

Changing trends in the surgical treatment of coarctation of the aorta.

From 1974 through 1983, 107 patients 4 days to 27 years old underwent 115 operations for treatment of coarctation of the aorta. Thirty-two patients were infants (1 year old or younger), and 28 of them were newborns. All newborns were seen with congestive heart failure. Seventy-one patients were seen with hypertension. Associated anomalies were present in 72 patients (67%). Resection was performed in 48 patients, patch aortoplasty in 16, bypass of the coarcted segment in 15, and left subclavian artery flap angioplasty (LSAFA) in 36. Ligation of a patent ductus arteriosus was simultaneously performed in 28 patients and pulmonary artery banding, in 4. Follow-up was 6 months to 9.2 years. There was a significant difference in aortic cross-clamp time between 26 patients who had resection (37.9 +/- 12.9 minutes) (mean +/- standard deviation) and 32 patients who had LSAFA (22.9 +/- 7.7 minutes) (p less than 0.05). Six patients died within thirty days after operation; 5 of them had resection, and 1 had bypass. Major postoperative complications included bleeding requiring exploration in 3 patients (2 after resection and 1 after LSAFA) and paraplegia in 1 patient after reoperation (resection) for recurrent coarctation 3 years after patch aortoplasty. Paradoxical hypertension was observed in 13 patients, and sustained systemic postoperative hypertension developed in 11 after effective repair of coarctation. There was no significant difference in early postoperative arm-leg pressure gradients between the types of operation or the various age groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Alterations in biomarkers of endothelial function following on-pump coronary artery revascularization.

Background: Cardiopulmonary bypass (CPB) has been associated with activation and injury of endothelial cells, probably responsible for the systemic inflammatory response syndrome (SIRS) taking place in these patients. Methods: We measured plasma concentrations of soluble P‐selectin (sP‐s), E‐selectin (sE‐s), tetranectin (TN), vonWillebrand factor (vWF) levels, and angiotensin‐converting enzyme (ACE) activity in 31 adult patients undergoing elective coronary artery bypass grafting, just before and up to three days after surgery, and in 25 healthy volunteers. Results: Patients showed higher plasma sP‐s and sE‐s and ACE concentrations, just before surgery, but significantly lower TN levels, compared with controls. During the first three postoperative days (PD), the concentration of each of the molecules followed a different and independent pattern, although in the third PD, the levels of sP‐s, sE‐s and ACE were higher and those of vWF and TN lower, compared with the preoperative ones. However, patients had higher sP‐s (P=0.06), sE‐s (P=0.07), and vWF (P=0.005), but lower TN concentrations (P=0.02) on the third PD compared with controls. Conclusions: CPB is characterised by pronounced changes in plasma sP‐s, sE‐s, TN, vWF levels, and ACE activity, which are associated with significant alteration in the intra‐ and early postoperative endothelial function observed in open heart surgery. J. Clin. Lab. Anal. 24:389–398, 2010.

Perioperative use of iloprost in cardiac surgery patients diagnosed with heparin‐induced thrombocytopenia‐reactive antibodies or with true HIT (HIT‐reactive antibodies plus thrombocytopenia): An 11‐year experience

Thrombocytopenia and thromboembolism(s) may develop in heparin immune‐mediated thrombocytopenia (HIT) patients after reexposure to heparin. At the Onassis Cardiac Surgery Center, 530 out of 17,000 patients requiring heart surgery over an 11‐year period underwent preoperative HIT assessment by ELISA and a three‐point heparin‐induced platelet aggregation assay (HIPAG). The screening identified 110 patients with HIT‐reactive antibodies, out of which 46 were also thrombocytopenic (true HIT). Cardiac surgery was performed in HIT‐positive patients under heparin anticoagulation and iloprost infusion. A control group of 118 HIT‐negative patients received heparin but no iloprost during surgery. For the first 20 patients, the dose of iloprost diminishing the HIPAG test to ≤5% was determined prior to surgery by in vitro titration using the patients’ own plasma and donor platelets. In parallel, the iloprost “target dose” was also established for each patient intraoperatively, but before heparin administration. Iloprost was infused initially at 3 ng/kg/mL and further adjusted intraoperatively, until ex vivo aggregation reached ≤5%. As a close correlation was observed between the “target dose” identified before surgery and that established intraoperatively, the remaining 90 patients were administered iloprost starting at the presurgery identified “target dose.” This process significantly reduced the number of intraoperative HIPAG reassessments needed to determine the iloprost target dose, and reduced surgical time, while maintaining similar primary clinical outcomes to controls. Therefore, infusion of iloprost throughout surgery, under continuous titration, allows cardiac surgery to be undertaken safely using heparin, while avoiding life‐threatening iloprost‐induced hypotension in patients diagnosed with HIT‐reactive antibodies or true HIT. Am. J. Hematol. 90:608–617, 2015.