John B. Flege

Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax

BACKGROUND Chylothorax is a challenging clinical problem. Untreated, it carries a high mortality and morbidity. Traditional surgical management for cases refractory to conservative treatment is thoracic duct ligation through a right open thoracotomy. METHODS We describe 4 patients treated successfully by video-assisted thoracic surgery, using ports and no thoracotomy, and precise ligation and division of the thoracic duct just above the diaphragm. A pericardial window was made in the patient with chylopericardium, as in the patient with end-stage renal disease. Pleurodesis was used in the patient with esophageal carcinoma and the patient with jugular and subclavian vein thrombosis. RESULTS There were 2 women aged 18 and 42 years and 2 men, aged 61 and 65 years. No procedure-related mortality or morbidity occurred. In patients 1, 2, 3, and 4, the postoperative duration of drainage was 5, 7, 7, and 5 days, respectively (mean duration, 6 days) and the hospital stay, 5, 9, 10, and 5 days, respectively (mean stay, 7 days). There was no recurrence of chylothorax or chylopericardium during follow-up (range, 2 to 24 months; mean follow-up, 9 months). One patient died of esophageal carcinoma 4 months after operation. CONCLUSIONS Video-assisted thoracic surgery without a thoracotomy is an effective way of treating chylothorax and carries minimal morbidity.

Thoracoscopic internal mammary artery harvest for MICABG using the harmonic scalpel

BACKGROUND Thoracoscopic internal mammary artery (IMA) harvest is technically demanding, particularly on the left side. We have devised a Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) technique to facilitate this procedure, and describe our clinical experience here. METHODS The Harmonic Scalpel functions with ultrasonic energy, producing less smoke and lower heat than regular electrocautery. A total of 27 (22 left and 5 right) pedicles of the IMA in 23 patients were harvested from the upper margin of the first rib or higher to the lower margin of the fifth rib thoracoscopically using the Harmonic Scalpel with a hook blade. RESULTS In each case, the IMA harvest was completed thoracoscopically with only the Harmonic Scalpel, decreasing instrument transfers. Each vascular branch was coagulated without charring and was transected with excellent hemostasis. Smokeless views were provided. In the first 17 harvests, Doppler studies 3 months after the procedures demonstrated patent IMAs to the coronary circulation. CONCLUSIONS The Harmonic Scalpel facilitates thoracoscopic IMA harvest and is expected to minimize hyperthermic damage of the IMA.

Early results of thoracoscopic internal mammary artery harvest using an ultrasonic scalpel

OBJECTIVE We developed a thoracoscopic internal mammary artery harvest technique using an ultrasonic scalpel, the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH). This is the first report of 9 month follow-up using this technique. METHODS The Harmonic Scalpel is activated ultrasonically by vibrating at 55000 Hz. Compared with electrocautery, lower heat (<100 degrees C) and less smoke are generated. Thoracoscopic harvest using the Harmonic Scalpel with a hook blade was performed for 48 internal mammary arteries (42 left, six right) in 46 patients. Four (8.7%) of them were redo cases. The left internal mammary to left anterior descending artery and the right internal mammary to right coronary artery anastomoses were accomplished on the beating heart. Two left internal mammary arteries were sequentially, anastomosed to diagonal branches. Graft flow velocity was evaluated with pulsatile wave color Doppler test on the second or third postoperative day and repeated 3 and 6 months later. RESULTS The mean harvest time was 65 min (range 35-95 min) for the left internal mammary artery and 37 min (range 25-45 min) for the right internal mammary artery. One left internal mammary artery was lost due to intimal dissection. The Harmonic Scalpel-related morbidity was transient left phrenic palsy in one case and mild heat injury at the skin incision in the majority of cases. One Patient (2.2%) expired due to ischemic bowel on the second postoperative day. At a mean of 9 months follow-up, 45 alive patients have been free of angina. Doppler studies revealed diastolic augmentation of the graft flow velocity in 22 left and two right internal mammary arteries on the second or third postoperative day and 23 left and five right internal mammary arteries 3 and 6 months after operation. CONCLUSIONS Thoracoscopic internal mammary artery harvest is feasible and facilitated by the use of the Harmonic Scalpel. Early results of this technique are encouraging.

Successful balloon counterpulsation for right ventricular failure

We used pulmonary arterial balloon counterpulsation to treat successfully a patient with severe right ventricular failure following mitral valve replacement. The balloon was placed through a vascular graft sutured as a diverticulum to the main pulmonary artery.

Minimally Invasive Direct Coronary Artery Bypass for Redo Patients

BACKGROUND The minimally invasive direct coronary artery bypass (MIDCAB) procedure, using a small anterolateral thoracotomy without cardiopulmonary bypass, has been recommended for high-risk patients because it is less traumatic than conventional coronary artery bypass grafting. For redo patients who have patent grafts and pericardial adhesions, the MIDCAB may be preferable to the conventional operation because manipulation of the graft and dissection of adhesions may be minimized. METHODS Since November 1995, 120 patients underwent the MIDCAB procedure in our institution. Among these patients, there were 25 redo cases (20.8%). We reviewed these redo cases and studied their surgical results (mortality, morbidity, hospital stay, operation time, and postoperative inotropic support). To clarify the usefulness of this procedure, we compared the results of redo operations with those of the first-time operations. RESULTS For redo MIDCAB, there was one operative death (4%) because of intestinal infarction. The mean hospital stay was 4.3 days and the number of patients who needed postoperative positive inotropic agents was 3 (12%). There was no significant differences between redo and first-time operation patients in mortality, morbidity, hospital stay, operation time, and postoperative inotropic support. CONCLUSIONS Results of the MIDCAB procedure for redo patients were comparable to those for primary MIDCAB operations.

Sternotomy infection: Poor prediction by acute phase response and delayed hypersensitivity

Two hundred twenty-one consecutive adult cardiac surgical patients were examined prospectively for nutritional protein state, acute phase protein response, and delayed hypersensitivity reaction in an attempt to identify patients at high risk for the development of sternal wound infection, which occurred in 6 patients (2.7%). There was no significant correlation between preoperative nutritional protein concentrations (retinol-binding protein, prealbumin, and transferrin) and acute phase protein levels (C-reactive protein, alpha 1-acid glycoprotein, and complements B and C3), nor a statistically significant relationship between nutritional state or acute phase protein response and the development of sternal infection. Preoperative complement C3 levels were elevated, however, in 80.0% of those in whom sternal infections developed compared with 30.6% of those with well-healed wounds. Similarly, postoperative concentrations of alpha 1-acid glycoprotein were elevated in 80.0% of those in whom sternal infections developed compared with 28.6% of those with well-healed wounds. There was no correlation between delayed hypersensitivity and the risk of sternal infection, nor between preoperative nutritional protein and acute phase protein values. Seventy-three percent of patients were anergic on postoperative day 2. Stepwise logistic regression showed that age, body weight, preoperative intensive care unit stay, repeat median sternotomy, internal mammary artery grafting, postoperative hemorrhage, and postoperative cardiac arrest correlated with the development of sternal infection, whereas transfusion requirement, reexploration for bleeding, and the operation performed did not. We conclude that routine delayed hypersensitivity testing is of no value in predicting high-risk cardiac surgical patients when the anergy battery is placed on the preoperative day. Although statistically insignificant, possibly due to the small number of patients in whom sternal infection developed in this study (type II error), a larger study might find preoperative complement C3 and post-operative alpha 1-acid glycoprotein levels to be predictive of patients at risk for the development of sternal wound infection. The final logistic model for the predicted risk 2%) of sternal wound infection is: PREDSWC = exp(EQ)/1 + exp(EQ) where EQ = (0.38 x age) + (0.24 x weight) + (5.42 x preop ICU) + (4.39 x redo) + (7.14 x IMA) + (4.49 x hemorrhage) + (8.81 x arrest) - 62.72, and where preop ICU, redo, hemorrhage, and arrest are defined as yes (1) or no (0), IMA-is defined as 0, 1, or 2, age is in years, and weight is in kilograms.

Coronary Artery Bypass Surgery Following Thrombolytic Therapy for Acute Coronary Thrombosis

One hundred thirty-six patients underwent thrombolytic therapy for acute evolving myocardial infarction from June, 1981, through December, 1982. Of these patients, 51 underwent coronary bypass procedures from two hours to 90 days (average, 16 days) following thrombolytic therapy. Six (12%) had single-vessel disease, 15 (29%) had double-vessel disease, and 30 (59%) had triple-vessel involvement. Ejection fraction values ranged from 21 to 60%. The average number of grafts performed per patient was 3.4. There were no operative deaths in this series. Postoperative hemorrhagic problems were minimal, and the incidences were no different from those for other coronary bypass patients. In follow-up ranging from 2 to 18 months, there was no recurrence of severe angina or other clinical evidence of saphenous graft occlusion in the thrombolysed vessels. Of the 45 patients eligible to return to work, 40 (89%) have done so. The data from this series suggest that surgical myocardial revascularization after intracoronary thrombolytic infusion for acute myocardial infarction can be performed safely and that complete recovery and a high return-to-work ratio can be anticipated.

Twenty-Year follow-up of saphenous vein aortocoronary artery bypass grafting

The clinical records of our first 100 patients to undergo saphenous vein aortocoronary bypass grafting were reviewed. The procedures were performed between March 19, 1970, and March 30, 1972. The patient population included 84 men, and the mean age was 51.4 years. There were 12 patients with single-vessel disease, 36 with double-vessel disease, and 52 with triple-vessel disease, for an average of 2.4 involved vessels per patient. Forty-eight patients were judged to have diffuse atherosclerotic disease. Twelve patients had left main coronary artery stenoses. Each patient received an average of 1.8 saphenous vein grafts. Thirty-six patients underwent repeat coronary artery bypass grafting after an average of 132.8 months and received an average of 3.5 grafts. This resulted in cumulative reoperative rates of 5%, 14%, 27%, and 36% at 5, 10, 15, and 20 years, respectively. The 5-, 10-, 15-, and 20-year survival rates were 89.8%, 68.4%, 53.1%, and 40.8%, respectively. Survival was not significantly related to the cause of death, cardiac-related causes being predominant. There were no significant relationships between the length of survival and sex, the number of grafts received, or the presence of left main stenosis. Survival was inversely related to age at initial operation (p = 0.046) as well as initial left ventricular end-diastolic pressure (p = 0.033). Survival positively correlated with the occurrence of triple-vessel disease (p = 0.031) and the presence of diffuse disease (p = 0.0077).(ABSTRACT TRUNCATED AT 250 WORDS)

Transventricular aortic cannulation for repair of aortic dissection

We have used transventricular aortic cannulation as arterial inflow from the heart-lung machine in seven consecutive operations done in 1 year for acute aortic dissection. Satisfactory cardiopulmonary bypass was achieved in all patients.

Combined Valvular and Coronary Artery Surgery

Between July 1, 1971, and March 1, 1975, 45 patients underwent combined valvular and coronary artery operation. Aortic valve disease was present in 30 patients, mitral valve disease in 13, aortic and mitral valve disease in 1, and tricuspid valve disease in 1. The average age was 57 years. Seventeen patients were in New York Heart Association Functional Class IV. Seventeen patients had had a previous myocardial infarction. Significant coronary artery disease was an unexpected finding at the time of coronary angiography in 14 patients. The average number of grafts inserted was 2.5 per patient. The grafts were placed prior to valve replacement, and periods of myocardial ischemia were kept at a minimum by maintaining coronary perfusion throughout the operation. Operative mortality was 16%; late mortality was 8%. Perioperative myocardial infarction occurred in 2 patients.