John L. Ochsner

Aprotinin for Primary Coronary Artery Bypass Grafting: A Multicenter Trial of Three Dose Regimens

BACKGROUNDnHigh-dose aprotinin reduces transfusion requirements in patients undergoing coronary artery bypass grafting, but the safety and effectiveness of smaller doses is unclear. Furthermore, patient selection criteria for optimal use of the drug are not well defined.nnnMETHODSnSeven hundred and four first-time coronary artery bypass grafting patients were randomized to receive one of three doses of aprotinin (high, low, and pump-prime-only) or placebo. The patients were stratified as to risk of excessive bleeding.nnnRESULTSnAll three aprotinin doses were highly effective in reducing bleeding and transfusion requirements. Consistent efficacy was not, however, demonstrated in the subgroup of patients at low risk for bleeding. There were no differences in mortality or the incidences of renal failure, strokes, or definite myocardial infarctions between the groups, although the pump-prime-only dose was associated with a small increase in definite, probable, or possible myocardial infarctions (p = 0.045).nnnCONCLUSIONSnLow-dose and pump-prime-only aprotinin regimens provide reductions in bleeding and transfusion requirements that are similar to those of high-dose regimens. Although safe, aprotinin is not routinely indicated for the first-time coronary artery bypass grafting patient who is at low risk for postoperative bleeding. The pump-prime-only dose is not currently recommended because of a possible association with more frequent myocardial infarctions.

Homologous veins as an arterial substitute: Long-term results

From 1968 through 1982, 129 homologous vein grafts were used in 91 patients in the following positions: 75 in the femoropopliteal, tibial, or peroneal artery; 38 in the aortocoronary artery; 13 in the aortopulmonary artery; and one each in the atrioventricular fistula, carotid-subclavian artery, and brachial-radial artery. In the lower extremity patency ranged from 0 to 121 months (mean 22.4 +/- 4.4 months). All grafts were performed for limb salvage, and 75% of the patients had undergone previous operations. Cumulative patency by the life-table method showed that while 50% of grafts occluded by 1 year, 60% of the remaining grafts continued to be functional for more than 5 years. Fifty percent of the aortocoronary bypass grafts studied were occluded at 1 year. Eight of the 13 systemic pulmonary artery shunts were patent at time of death, revision, or total correction. Multiple revisions and thrombectomies are required to maintain patency of homograft veins. The outcome is variable and unpredictable. The inconsistency is due to the antigenicity of the graft. If one is committed to the necessary efforts required to ensure long-term patency, the homologous saphenous vein is a suitable substitute when autogenous tissue is unavailable.

Surgical Management of Diseased Intracavitary Coronary Arteries

An intracavitary location of a coronary artery is rare in our surgical experience with myocardial vascularization. This variant has occurred in the right coronary artery (0.09%) and in the left anterior descending coronary artery (0.2%). The location of the lesion and the pathological condition, length, and size of the coronary artery may dictate exposure of an intracavitary coronary artery for proper revascularization. More commonly, surgeons are unaware of the intracavitary position and during intramyocardial dissection of an artery will open a cardiac chamber where the vessel traverses the cavity. Problems that arise are introduction of air, difficulty in exposure due to blood and depth of position, and obstruction of the coronary artery during closure of the myotomy. We report here on 13 patients who required revascularization of intracavitary vessels (four right coronary arteries and six left anterior descending coronary arteries). The location and length of the intracavitary portion of the artery determined the surgical management. The methods used to close the cavity varied. The techniques employed were simple closure; moving the artery into an aerial position with cavitary closure behind it; anastomosis in the intracavitary position with closure of the myotomy around the graft; or selection of an alternate distal site for anastomosis. All patients treated for intracavitary arteries were successfully revascularized without major complications.

A Modified Sternal Retractor

A modification of the Favaloro sternal retractor is described that allows a singel person to operate the apparatus when elevating the sternal plate. The new retractor is also easier on the sternum because of its blunter teeth.

Revascularization in severe ventricular dysfunction (15% ≤ LVEF ≤ 30%): a comparison of bypass grafting and percutaneous intervention

BACKGROUNDnWe sought to determine the optimal approach to revascularization of patients with severe left ventricular (LV) dysfunction.nnnMETHODSnWe conducted a single-center observational study of 117 consecutive patients who had severe LV dysfunction (15% < OR = LV ejection fraction < OR = 30%) and underwent either coronary artery bypass grafting (CABG, n = 69) or percutaneous revascularization (n = 48) between 1992 and 1997.nnnRESULTSnThe CABG group was younger (62 versus 67 years, p = 0.026), and fewer previous bypasses (7% versus 40%, p < 0.0001) and fewer prior percutaneous revascularizations (16% versus 42%, p = 0.0019) were noted. More vessels were revascularized (3 +/- 0.8 versus 1.5 +/- 0.7, p < 0.0001), and revascularization was more complete by CABG (84% versus 48%, p < 0.0001). Morbidity and mortality at 30 days were similar, and there was no significant difference in 3-year survival (73% versus 67%), although 3-year cardiac event-free survival (52% versus 25%, p = 0.0011) and 3-year target vessel revascularization-free survival (71% versus 41%, p < 0.0001) were significantly better in the CABG group, and LV ejection fraction was significantly improved after CABG. In the subgroup of patients 65 years of age or older and those without proximal left anterior descending coronary artery lesions, significant benefit of CABG in cardiac event-free and target vessel revascularization-free survival disappeared.nnnCONCLUSIONSnWe found that in clinically selected patients with severe ventricular dysfunction, CABG compared with percutaneous revascularization achieves more complete revascularization, improved LV function, fewer cardiac events, and fewer target vessel revascularizations, but does not affect mid-term survival. A prospective controlled trial with defined criteria for treatment assignment is warranted to confirm our results regarding the two revascularization strategies in patients with severe LV dysfunction.

Atrial Replacement and Tricuspid Valve Reconstruction After Angiosarcoma Resection

A cardiac angiosarcoma was resected and successfully managed by replacement of the right atrium and bileaflet reconstruction of the tricuspid valve by conserving non-involved valvular tissue. Competency of the new valve was confirmed intraoperatively by transesophageal echocardiography and reconfirmed at discharge. Evaluation 3 months postoperatively revealed no evidence of valvular insufficiency or right heart failure. In selected patients, resection of extensive primary cardiac neoplasms may be possible without necessitating prosthetic valve replacement.

Positive End-Expiratory Pressure in the Management of the Patient with a Postoperative Bleeding Heart

This prospective study involves 406 consecutive adults who had heart operation with extracorporeal circulation. Fifteen patients (3.7%) bled at the rate of 200 ml per hour or more in the postoperative period. Thirteen of the 15 patients who bled had undergone coronary artery operation. After all clotting factors and, when applicable, hypertension had been checked and corrected, positive end-expiratory pressure (PEEP) was used in managing the bleeding of these patients. Before institution of PEEP, the average bleeding was 330 ml per hour for one to five hours. After PEEP was instituted in the 11 patients in whom bleeding was controlled, an average output of 25 ml per hour for one to ten hours was recorded. Patients were kept on PEEP for 5 to ten hours. In 7 patients hemorrhage was controlled with 10 cm H2O of PEEP; 4 required 15 cm of PEEP to stop bleeding; 3 were explored for continuous bleeding on 15 cm of PEEP; and 1 was explored because of hypotension on 15 cm of PEEP. In 11 of the 15 patients who bled postoperatively (73%), operation was avoided by judicious use of PEEP. We believe that PEEP increases mediastinal pressure and that the overdistended lung can obliterate some bleeding in the mediastinum, thus controlling bleeding in many of these patients.

Pulmonary Artery Banding: Analysis of a 25-Year Experience

A 25-year experience (May 1962 through April 1987) with pulmonary artery banding in 183 patients was reviewed and analyzed. Pulmonary artery banding was performed in a heterogeneous group of patients aged two days to 60 months (median, 10 weeks; mean, 21.8 weeks) and weighing 1.4 to 13.8 kg (mean, 4.2 kg). Diagnosis was ventricular septal defect in 76 (41.5%) and atrioventricular communis in 41 (22.4%). Pulmonary artery banding was also used in patients with d-transposition of the great vessels with ventricular septal defect, double-outlet right ventricle, univentricular heart, tricuspid atresia, and truncus arteriosus. Early death occurred in 39 of 175 patients who underwent pulmonary artery banding at Ochsner Foundation Hospital (22.3%). Definitive operation has been performed in 37 of the patients who underwent pulmonary artery banding since 1979 with excellent outcome in 32 (86.5%). Pulmonary artery banding is a useful palliative procedure for a diverse group of patients with congenital cardiac anomalies and unrestricted pulmonary blood flow. With improved results of primary repair of intracardiac anomalies in small infants, however, pulmonary artery banding should be reserved for severely ill patients with complex lesions not amenable to early definitive correction. Currently, pulmonary artery banding is indicated in patients with excessive pulmonary blood flow and single ventricle or tricuspid atresia. Pulmonary artery banding is also appropriate in certain patients with atrioventricular communis and in patients with muscular or multiple ventricular septal defects. Pulmonary artery banding is an option in patients with ventricular septal defect and coarctation of the aorta.

Clinical Spectrum of Pulmonary Hamartomas

Pulmonary hamartomas are tumors that occur in the parenchyma or the bronchi. Through the lesions themselves are benign, they may be associated with malignant neoplasms or they may cause obstruction of the bronchi because of their location. Pulmonary hamartomas were resected in 29 patients at the Ochsner Medical Institutions during a 30-year period. Of these patients, 6 had symptoms related to concomitant malignancy and 3 had symptoms resulting from obstruction of the bronchi by the hamartoma. Surgical treatment ranged from enucleation to pneumonectomy. One patient died in the hospital of extensive bronchogenic carcinoma. In 2 others, carcinoma of the lung developed within twelve months after resection of a hamartoma. In this group of patients, 20% had concomitant or subsequent pulmonary lesions. Ten percent of the hamartomas were located in the bronchi, resulting in bronchial obstruction. A surgical approach is indicated for lesions that appear to be pulmonary hamartomas on roentgenograms.

Long-Term Follow-up of Internal Mammary Artery Myocardial Implantation

A study was made of 100 patients who had undergone internal mammary artery myocardial implantation 7 to 10 years previously. Forty-two patients had single implantation with or without a free omental graft, and 54 received double implantations. Four patients had a single internal mammary artery implant plus a single aortocoronary bypass graft. Eleven patients died at operation or within the first month, and 17 died from 1 to 7 years following operation. Two were lost to follow-up, and 15 refused follow-up angiograms. From 7 to 10 years postoperatively, angiographic studies were performed on 55 patients with 73 internal mammary artery implants. Of these 73 implants, 17 (23%) were occluded; 10 (14%) were patent but did not show myocardial filling; 15 (21%) showed myocardial blush or filling of small vessels; and 31 (42%) showed filling of a major coronary artery. The patency rate correlated well with the amount of coronary disease and slightly with the amount of symptomatic improvement. This study shows that the Vineberg operation is physiologically sound; however, the ideal candidates are those patients with coronary arteries of adequate size who could benefit more by direct perfusion.