J. Nilas Young

Vascular complications of intraaortic balloon counterpulsation

Between February 1973 and December 1986, 4,787 patients underwent open heart surgery at Samuel Merritt Hospital. Retrospective analysis revealed 395 (8 percent) consecutive patients who required hemodynamic support with the intraaortic balloon pump. Thirty percent of the patients had preoperative placement, 56 percent needed the balloon in order to wean from cardiopulmonary bypass, and 14 percent required placement in the postoperative period. The intraaortic balloon pump was instituted with multiple techniques and insertion sites. Three hundred eighty-three balloon catheters (96 percent) were inserted through the groin by surgical cutdown or a percutaneous approach. The remaining devices were inserted through the aortic arch. A 12 F. catheter was utilized in 239 patients (61 percent) and a smaller 10.5 F. catheter was placed in 156 patients (39 percent). The hospital mortality rate was 47 percent. Seventy-two of the 395 patients (24 percent) sustained vascular complications related to balloon use. Major complications occurred in 43 patients. Twenty-nine patients sustained minor complications that resolved spontaneously with balloon removal. Risk factors evaluated included patient gender, New York Heart Association class, catheter size, method of introduction, duration of counterpulsation, and presence of symptomatic peripheral vascular disease. Since percutaneous placement was associated with a significant decrease in complications, we concluded that use of the smaller 10.5 F. catheter placed percutaneously is the safest means of employing the intraaortic balloon pump. A monitoring line is placed percutaneously through the femoral artery in high-risk patients before operation. This allows easier access for intraaortic balloon pump placement in hypotensive patients. The presence of a clinical history of peripheral vascular disease was also a highly significant risk factor for vascular complications. Other risk factors increasing the likelihood of vascular compromise included catheter size and duration of counterpulsation.

Closure of bronchopleural fistulas by an omental pedicle flap

Bronchopleural cutaneous fistulas are a serious problem that are difficult to treat with any assurance of success. Thoracoplasty, muscle pedicle grafts, and attempts at reclosure have been used with limited success. We have used the omental flap technique in the management of five patients with bronchopleural cutaneous fistulas. In our patients and in four cases in the literature, the success rate has been 100 percent. The omental pedicle flap is a simple way to close bronchopleural fistulas. It avoids extensive chest wall dissection and destruction in patients who often have marked respiratory embarrassment and other underlying disease. The results have been excellent.

Descending thoracic aortic aneurysm: A 10 year surgical experience

Presently we favor heparinless femorofemoral venoarterial bypass for all descending thoracic aneurysm resections. The advantages are minimal blood loss due to the absence of heparin, ease of insertion, especially in large aneurysms where it would be difficult to insert a temporary shunt, distal aortic perfusion, possibly a safety factor in preventing spinal cord and visceral ischemia, and prevention of left heart overload and myocardial failure. In acute traumatic ruptures, simple aortic cross clamping is a suitable alternative. It is safe and can be carried out expeditiously in any community hospital where bypass facilities may not be available. Proximal hypertension can be controlled pharmacologically. We have also used this successfully in ruptured atherosclerotic aneurysms. We have no experience with temporary tridodecylmethylamonium (TDMAC) shunts; several groups have used them successfully. We believe they may be difficult to insert in the proximal aorta with a large mediastinal hematoma or extensive aneurysm. Cannulation of the left ventricular apex necessitates cardiac manipulation and may produce effective aortic valve insufficiency. In patients with aortoesophageal and bronchoesophageal fistula, permanent extrathoracic bypass is preferable to a prosthetic graft in a contaminated field. We propose using a permanent bypass with a no. 10 or 12 right axillofemoral bypass. Our experience is limited to only two patients. This is also a method of treating a mycotic aneurysm or infected thoracic aortic graft.

Autologous blood retrieval in thoracic, cardiovascular, and orthopedic surgery

A significant amount of red blood cells were conserved with use of the Cell Saver in cardiac surgery patients and in some orthopedic and vascular surgery patients. No major complications have been associated with its use in our cases. Our results are similar to those of others who have reported on the use of this device. In the cardiac surgery patients we observed significant serum protein losses which had to be replaced. We recommend the use of intraoperative albumin to help maintain adequate urinary output and hemodynamic stability.

Early detection and management of left ventricular free wall rupture during acute myocardial infarction

Abstract Left ventricular free wall rupture is generally perceived to be universally fatal. 1–3 Although most patients who have rupture with acute pericardial tamponade die rapidly, the process may be slow enough to permit diagnosis and successful management. 4–6 We present our experience with 2 patients in whom surgical management of ventricular free wall rupture was accomplished successfully.

Porcine heparin increases postoperative bleeding in cardiopulmonary bypass patients

SummaryOne hundred thirteen patients undergoing cardiopulmonary bypass were randomly assigned to receive either bovine or porcine heparin. Heparin was infused at 4.5 mg/kg during bypass and administered at the lesser of 70 units/kg or 5000 units/dose at 12-hour intervals postoperatively. Platelet counts decreased to 45% of preoperative levels during the first 3 days postoperatively (porcine, 44±13%, n =50; bovine, 46±15%), but returned to preoperative levels by the seventh postoperative day. The average blood loss in the porcine heparin group significantly exceeded that of the bovine heparin group (porcine, 1350.7±727.8 ml; bovine, 1059.6±381.0 ml; p<.01). Consequently, the platelet transfusion requirement was greater in the porcine heparin group (porcine, 1.7±3.9 units; bovine, 0.5±1.7 units; p<.05); however, blood and blood component (with the exception of platelets) administration was not significantly different between the two groups. The four patients taking anticoagulants or antiinflammatory agents in the porcine group required a mean of 8.5 units of red blood cells (RBC) plus supplemental platelets. The seven such patients in the bovine group received a mean of 3.0 units of RBC and no platelets. Thus, the use of porcine heparin resulted in a generalized increase in postoperative bleeding with increased management problems in patients undergoing cardiopulmonary bypass.

Late recurrent rupture of a sinus of Valsalva aneurysm

Abstract Sinus of Valsalva aneurysms are rare and usually of congenital origin. Their exact incidence is unknown due to their tendency to remain asymptomatic until the time of rupture. Both primary closure and patch repair of the defect are used depending on the characteristic of the lesion. Hospital mortality has ranged from 0 to 5% in recent series, 1–3 and most patients return to normal health after recovery from surgery. Recorded instances of recurrent fistula formation are unusual. 1,4 Most are reported to occur in the immediate postoperative period or several years after surgery. The mean follow-up in most series is ≤ 10 years. 3,4–6 We report a case of fistula recurrence 30 years after initial repair.

A Technique for Avoidance of Hypothermia During Prolonged Mechanical Circulatory Support with Centrifugal Pumps

Systemic hypothermia became a major problem in one of our patients undergoing postcardiotomy mechanical circulatory support with a centrifugal pump. We have developed a technique to prevent systemic hypothermia in this setting by applying an adapted topical cardiac cooling device to the centrifugal pump heads.