J. Ernesto Molina

Thrombolytic therapy for postoperative pulmonary embolism

The use of thrombolytic agents in the treatment of postoperative pulmonary embolism presents a dilemma to the surgeon. On one hand, postoperative pulmonary embolism usually occurs within 2 weeks of surgery. On the other hand, recent surgery is considered a contraindication for the use of thrombolytics. We developed a protocol for treating pulmonary embolism patients who have recently undergone surgery. Urokinase, at a dose of 2,200 U/kg wt, is injected directly into the clot via a catheter positioned in the pulmonary artery. This is followed by continuous infusions of urokinase at 2,200 U/kg wt/hr until the clot is lysed (up to 24 hrs). Simultaneously, heparin is administered peripherally at 500 U/hr. The level of serum fibrinogen is monitored every 6 hours and maintained at no less than 0.2 g/dL to prevent bleeding. Thirteen patients were treated for angiographically proven pulmonary embolism within 14 days of surgery. Complete lysis of every embolus was achieved, and no deaths or bleeding complications occurred. Two patients received inferior vena cava filters, and nine patients no longer needed chronic anticoagulants within 3 months after the embolic event.

Undertreatment and overtreatment of patients with infected antiarrhythmic implantable devices.

BACKGROUND Infection of implantable defibrillators or pacemakers is a serious complication, reported with increasing frequency probably because of an increase in the total number of devices implanted due to a change in trends in the treatment of arrhythmias. This review is aimed to provide guidelines on how to deal with these infections and which method is most likely to be successful. METHODS This is a review of 38 patients with infected antiarrhythmic implantable devices under three different plans of therapy. There were 17 implantable cardioverter defibrillators and 21 pacemakers. In 27, infection occurred after primary implantation (15 pacers, 12 implantable cardioverter defibrillators), and in 11 after replacement (six pacers, five implantable cardioverter defibrillators). Three therapeutic plans were identified. Group I (n = 12) received intravenous antibiotics without removal of the antiarrhythmic implantable device, but with relocation to a different area or plane, and with or without the use of a topical irrigating-suction system. Group II (n = 19) had complete removal of the system, 2 weeks of intravenous antibiotics, and implantation of a new unit followed by 10 more days of antibiotics. Group III (n = 7) underwent complete removal, 6 weeks of antibiotics, implantation of a new unit, and another 6 or more weeks of antibiotic therapy. RESULTS Failure occurred in 100% of cases in group I. Groups II and III had complete clearing of infection and successful reimplantation of new systems with no recurring infections. Follow-up was 8 months to 5 years. Two deaths occurred, both in group I. Hospitalization for groups I and III was 104 days and 65 days, respectively, versus 22 days for group II. No deaths occurred in group II or III. CONCLUSIONS With an infected antiarrhythmic implantable device, immediate removal of the entire unit is recommended, followed by 2 weeks of intravenous antibiotics, implantation of a new system, and 10 more days of postoperative antibiotics. This regimen is sufficient to cure the problem. No attempts should be made to save an infected system from removal because it endangers the patients life, prolongs hospitalization, increases costs, and most likely will fail.

Primary closure for infected dehiscence of the sternum

I propose a new irrigation-suction system to achieve primary closure of the sternum in cases of postoperative infected dehisced sternotomy. Of 16 cases, I had no treatment failures, no recurring infections, and no patient deaths after 1 to 8 years of follow-up. The new system entails retrosternal and superficial sets of tubes, both in double-staggered position, with primary closure of the sternum and of the skin. Skin or muscle flaps are avoided, and the stability of the chest cage is maintained. Hospitalization time is 14 to 18 days.

Protocols for Paget-Schroetter Syndrome and Late Treatment of Chronic Subclavian Vein Obstruction

BACKGROUND Paget-Schroetter syndrome is a serious condition that if not treated promptly and properly leads to severe sequelae and permanent disability. In its late stage, chronic fibrous obliteration of the vein is rarely amenable to surgical treatment, except in very few select cases. METHODS We treated 126 Paget-Schroetter syndrome patients (group I) by implementing an emergency protocol of thrombolysis by catheter-directed infusion, followed by immediate surgery through an anterior subclavian approach entailing (1) decompression of the thoracic inlet and (2) repairing the vein with a vein patch to reestablish its normal caliber. In addition, we treated another selective group of 81 patients (group II) for chronic fibrotic obstruction several months after their original event, but only when the inflow was adequate. RESULTS Our acute emergency care resulted in a 100% long-term patency rate in group I, with no sequelae. The patency rate in group II was 100% as well, but in 74% a long vein patch, endovascular stents, or homograft implants were used. CONCLUSIONS Implementation of an emergency approach to treat Paget-Schroetter syndrome is highly recommended to prevent the delayed sequelae of permanent subclavian vein obliteration and disability. In chronic obstruction, when feasible, we recommend a long saphenous vein patch, followed by endovascular stent implant.

A new surgical approach to the innominate and subclavian vein

A new technique extending the incision used for thoracic outlet decompression with a subclavicular approach to the first rib is presented. After the first rib and scalenotomy are removed, the subclavicular incision is continued into the sternum medially and superiorly to the sternal notch. This gives easy access to the innominate-subclavian-axillary vein segment. Eight patients with extensive chronic fibrotic obstruction of the subclavian-innominate vein segment underwent operation with this technique. It allows placement of either long patches of saphenous vein to reestablish normal caliber or replacement, as is our choice, with a small-sized cryopreserved descending thoracic aortic homograft. The operation is carried out in an extrapleural plane preserving the sternoclavicular joint, avoiding the deformity caused by transclavicular techniques. Repair of the sternotomy creates a stable incision. Follow-up to 14 months shows patency of the venous channel with no complications. This surgical approach is recommended to solve the problem of satisfactory exposure of the subclavian-innominate venous channel after decompression of the thoracic outlet.

Perforation of the Right Ventricle by Transvenous Defibrillator Leads: Prevention and Treatment

A series of 78 consecutive implants of the transvene PCD (Medtronic, Inc.) defibrillator system is presented and the occurrence of right ventricular perforation in 4 patients reported (5.2%). Diagnosis of perforation is made using four signs: (1) decrease in arterial blood pressure without any other explanation; (2) decrease in pulsatility of the cardiac silhouette as monitored by fluoroscopy; (3) increased size of the cardiac silhouette; and (4) abnormal position of the transvenous lead too far out toward the left ventricle along the pericardial outline. Perforation causes rapid and dramatic cardiac tamponade due to the large diameter and stiffness of the coil carrier lead. Immediate drainage of the hemopericardium must be carried out using the transxiphoid approach. The use of a thin blue‐coded lead stylet (0.014‐inch gauge) is recommended over the stiffer maroon‐coded stylet. Since treatment must be carried out immediately, it is advised that a surgeon either perform, assist, or be immediately available whenever one of these systems is implanted.

Thrombolytic Therapy for Iliofemoral Venous Thrombosis

The authors outline a new approach to management of ileofemoral venous thrombosis: direct thrombolysis of the clot; identification of the cause of the thrombosis (usually iliac vein stenosis); then treatment of the obstructive process by balloon dilation, with or without the use of expanded stents; and reestablishment of venous flow.

Surgical options for endocardial lead placement when upper veins are obstructed or nonusable.

In 35 patients (24 adults, 11 children), two techniques were used to implant endocardial pacemaker or defibrillator leads in the presence of complete occlusion or nonusability of upper veins. The obstructed veins were the subclavian, innominate, and superior vena cava (SVC). Most of the obstructions occurred secondary to previous implant of multiple leads. Twenty-four patients had occlusion of the subclavian veins; 7 of both the subclavians and innominates; 4 had stenosis of the SVC. Twenty-seven patients with obstructed subclavian veins, but with patent innominates, underwent direct implants via cut-down internal jugular vein for one or two leads, as needed. Eight patients with obstructed innominate veins or SVC underwent a direct transthoracic transatrial approach (TTTA). This method involves a parasternal extrapleural route through the mediastinum to directly puncture the right atrium. The leads are then implanted endocardially, under fluoroscopy. There were no complications with either method, and the implanted units have been working well during up to 14 years follow-up. These two techniques circumvent the problem of obstructed upper veins—which limits the options for implanting endocardial pacing systems.

An epicardial subxiphoid implantable defibrillator lead: Superior effectiveness after failure of Standard implants

A single epicardial implantable lead using the subxiphoid approach is described in this article. It consists of a single halo‐shaped coil that is implanted under the inferior surface of the heart, including the right and left inferior ventricular surfaces. It has been implanted in four patients who could not be defibrillated with a transvenous system, even with the adjunct use of subcutaneous leads or left chest wall patch. Three of the patients had progressive heart failure due to ischemic myocardiopathy; the fourth patient had a dilated idiopathic myocardiopathy. The approach is simple and appears to be effective due to its ability to encompass the left and right ventricles. This vector seems to significantly lower the threshold for defibrillation, and may offer substantial benefit in the setting of high defibrillation thresholds with conventional leads, or when conventional systems are inadequate to achieve consistent defibrillation.

Combined posterior and transaxillary approach for neurogenic thoracic outlet syndrome

BACKGROUND Incomplete removal of the first rib in operations intended to decompress the thoracic outlet is often seen after the single transaxillary approach (often leaving a posterior stump) or supraclavicular techniques (leaving an anterior stump). The former may also cause neurogenic and vascular injuries because the exposure is often poor in attempting complete removal of the first rib posteriorly and the surgeon faces a significant struggle. STUDY DESIGN A new operative procedure is described entailing two stages using two separate incisions: a transaxillary and posterior incision done at the same sitting that accomplishes complete removal of the first rib with less risk. This combined approach is done with the help of a new arm holder device during the transaxillary stage followed by a small incision behind the trapezius ridge for posterior access to the rib. RESULTS I present 33 patients in whom this operation was implemented, with a cure rate of 79%, improvement in 15%, and unchanged in 6%, with no complications or mortality. Technical details are presented. CONCLUSIONS A double-incision approach is recommended as a safer and more effective method to accomplish complete removal of the first rib than are single transaxillary supraclavicular techniques in cases with thoracic outlet obstruction.