Jeffrey P. Gold

Late cardiac perforation following transcatheter atrial septal defect closure

Transcatheter closure of secundum atrial septal defect (ASD) has become an alternative to surgery. We present a patient with hemodynamic collapse secondary to cardiac perforation occurring 6-months after the placement of an Amplatzer Septal Occluder and discuss the utilization/complications of this device.

Pacemaker backup-mode reversion and injury during cardiac surgery

Both electrocautery and internal defibrillation are routinely used in cardiac operations. The cases of 5 patients are presented in whom backup-mode reversion or injury of permanently implanted pulse generators occurred during a cardiac procedure. The theoretical explanations for backup-mode reversion and generator or tissue injury are discussed, and recommendations are made for the management of patients with a pacemaker who are to undergo a cardiac operation.

Triple sequential grafts using the internal mammary artery : an angiographic and short-term follow-up study

Between December 1984 and December 1988, coronary artery bypass operations, involving the use of 119 sequential internal mammary artery grafts with three or more anastomoses per conduit, were performed in 116 patients. Patients included 14 women and 102 men, with a mean age of 60 years. They received a total of 629 anastomoses; 373 anastomoses were used in multiple sequential arterial bypass grafts; 116 sequential left and three right internal mammary artery jump grafts were performed. There were 27 patients with bilateral internal mammary artery grafts, but only 17 had completely arterial revascularizations. Perioperative infarction occurred in 3.4 % of the patients; 1.7% of infarctions were related to sequential internal mammary artery grafts. There were no hospital deaths. Control angiography was performed within a month of the operation in 72 patients (with 371 anastomoses, of which 229 were in sequential arterial bypass grafts). The overall patency rate was 94.6 %, and for the internal mammary artery sequential graft with three or more anastomoses it was 96.1%. The mean follow-up period was 13 months; 110 patients were in New York Heart Association class I; there was one non-cardiac-related death, and three patients (2.6%) had a late myocardial infarction. One was related to the area revascularized by the sequential internal mammary artery graft. Multiple sequential internal mammary artery bypass grafts in coronary artery disease are feasible, with a high short-term patency and a low perioperative morbidity and mortality. (J T horac C ardiovasc S urg 1992;104:60–5)

Operative Management of the Calcified Patent Ductus Arteriosus

A technique in which the calcified adult patent ductus arteriosus can be safely divided using a left-sided thoracotomy approach without the need for transient aortic cross-clamping or cardiopulmonary bypass is described. Concentric, nested vascular clamps are placed on the noncalcified pulmonary artery side of the ductus, so that dissection and clamping of the heavily calcified ductus-aortic junction are unnecessary. The pulmonary artery rim surrounding the insertion of the ductus can be divided between the two clamps and oversewn.

Femorofemoral bypass to relieve acute leg ischemia during intra-aortic balloon pump cardiac support

This study reports our experience with 10 patients who underwent the emergent construction of a femorofemoral bypass graft to salvage an acutely ischemic lower extremity following the insertion of a transfemoral intra-aortic balloon pump catheter. All patients had excellent resolution of the ischemia and salvage of the extremity. Half of the procedures were done at the bedside with the remainder performed in the operating room. No long-term infections or ischemic sequelae resulted from the procedures in the nine patients available for long-term follow-up. The use of femorofemoral bypass grafting is, therefore, recommended in patients with severe ipsilateral limb ischemia who are dependent on an intra-aortic balloon pump to prevent extremity tissue loss as well as the systemic metabolic manifestations of ongoing tissue ischemia and necrosis. Patient selection, technical considerations, and postoperative management are discussed.

Nitrous Oxide for Blood Pressure Control after Coronary Artery Surgery: A Dose-Response Hemodynamic Study in Postoperative Patients

The inhaled anesthetic nitrous oxide is used for sedation in the coronary care unit and has been advocated as an antihypertensive agent in patients after a cardiac operation. To delineate the hemodynamic effects of nitrous oxide after cardiac surgery, we studied 11 patients with a mean age of 63 years who had undergone isolated coronary artery bypass grafting. All patients had major coronary artery disease and normal preoperative hemodynamic function. When patients were in stable condition in the intensive care unit, hemodynamic measurements were made at an inspired oxygen concentration of 40% with progressive doses of nitrous oxide (0, 10, 20, 40, and 60%). Measured and calculated hemodynamic data were compared using analysis of variance. Nitrous oxide caused significant decreases in mean arterial pressure in a dose-related fashion; pressure fell 6 mm Hg at 10% nitrous oxide and 11 mm Hg at 60% nitrous oxide (6 and 13% decreases). These changes were not associated with significant alteration in pulmonary artery pressure or cardiac index. Left ventricular stroke work index decreased significantly with the administration of nitrous oxide. We conclude that, in patients with normal hemodynamic and ventricular function, the administration of nitrous oxide for its sedative and antihypertensive effects is safe in the postoperative period and may be useful, especially in patients who are candidates for early extubation.