John W. Fehrenbacher

Prospective randomized study of a protein-based tissue adhesive used as a hemostatic and structural adjunct in cardiac and vascular anastomotic repair procedures.

BACKGROUND The purpose of this study was to determine whether adjunctive use of the bovine serum albumin and glutaraldehyde tissue adhesive BioGlue (BioGlue Surgical Adhesive; CryoLife, Inc) could reduce the rate of anastomotic bleeding in patients undergoing cardiac and vascular repair procedures when compared with a standard repair control. This was a prospective multicenter, randomized, controlled clinical trial conducted in accordance with the IRB at each participating institution. STUDY DESIGN A total of 151 patients consented to participation and were randomly assigned to standard repair plus BioGlue (n = 76) or standard repair alone (n = 75). These two groups were statistically homogeneous for age, gender, race, procedure, and number of anastomoses. Patients underwent cardiac procedures (n = 49), aortic procedures (n = 105), or peripheral vascular procedures (n = 48). RESULTS Anastomotic bleeding was significantly reduced in the BioGlue group (18.8% of anastomoses) compared with the control group (42.9% of anastomoses, p < 0.001). Pledget use was reduced in the BioGlue group (26.2%) compared with the control group (35.9%, p = 0.047). Days in the ICU and total days in the hospital were slightly higher in the control group. Adverse event profiles were equivalent between the two groups except for occurrence of neurological defects, which were threefold less in the BioGlue group (p = 0.009). CONCLUSIONS This study demonstrates that using BioGlue as an adjunct to standard repair methods is safe and significantly reduces the occurrence of intraoperative anastomotic site bleeding in cardiac and vascular repair patients. Using BioGlue along suture lines reinforces anastomoses, thus minimizing pledget use.

Angiosarcoma of the Aorta Associated with a Dacron Graft

Abstract The case report of a patient with an angiosarcoma arising near a Dacron aortic graft is presented with a review of the literature. Antemortem diagnosis of primary malignancies of the aorta and large arteries is seldom attained. The tumorigenic potential of plastic grafts is an etiological consideration.

Delayed postoperative bleeding from polytetrafluoroethylene carotid artery patches

Patch angioplasty of the internal carotid artery after endarterectomy has been advocated as a means of decreasing early postoperative carotid artery thrombosis, as well as reducing the incidence of recurrent carotid artery stenosis. Noninfectious rupture of saphenous vein patches in the early postoperative period has been reported by several authors, leading others to advocate the use of prosthetic patches. This report describes three patients in whom delayed bleeding through needle holes along the suture lines in polytetrafluoroethylene cardiovascular patches occurred between 1.5 and 4 days after operation. All patients required reexploration to control bleeding, and acute respiratory distress from tracheal compression developed in one patient. Although delayed bleeding through needle holes in polytetrafluoroethylene cardiovascular patches appears to be rare, a word of caution may be in order before advocating routine patching of the carotid artery with this particular type of patch.

Performance of the CryoValve* SG human decellularized pulmonary valve in 342 patients relative to the conventional CryoValve at a mean follow-up of four years

OBJECTIVE This study compared clinical outcomes of patients receiving CryoValve SG decellularized pulmonary valves with those of patients receiving conventionally processed CryoValve pulmonary valves. METHODS All consecutive patients undergoing Ross procedures and right ventricular outflow tract reconstructions with SG valves at 7 institutions (February 2000-November 2005) were assessed retrospectively (193 Ross procedures, 149 right ventricular outflow tract reconstructions). Patient, procedural, and outcome data were compared with those from 1246 conventional implants (665 Ross procedures, 581 right ventricular outflow tract reconstructions). Hemodynamic function was assessed at latest follow-up. RESULTS Follow-up was complete for 99% in SG group and 94% in conventional group, with mean follow-ups of 4.0 years (range, 0-6.7 years) for SG and 3.7 years (range, 0-6.7 years) for conventional. Five-year cumulative survivals and freedoms from adverse events were comparable between SG and conventional valves. Among patients undergoing Ross procedures, peak gradient at last follow-up was lower with SG valves (P < .01); no difference was observed in the right ventricular outflow tract reconstruction population. Pulmonary insufficiency was significantly reduced with SG valves in patients undergoing both Ross procedures (P < .01) and right ventricular outflow tract reconstructions (P < .01). Valve type was not a significant predictor of valve-related failure in propensity-adjusted analysis of either procedure. CONCLUSIONS CryoValve SG decellularized pulmonary valves have acceptable clinical outcomes and favorably compare with conventionally processed valves. Improved hemodynamic function observed with SG valves could signify improved long-term outcomes and may be due to the decreased antigenicity of these valves.

Proinflammatory Cytokine Effects on Mesenchymal Stem Cell Therapy for the Ischemic Heart

Mesenchymal stem cells (MSCs) hold great promise for improving myocardial recovery after ischemia. The cardiothoracic surgeon is uniquely positioned to be at the forefront of any clinical application of this therapy. As such, a basic understanding of stem cells and the cytokines that affect stem cell function will be an essential component of the surgeons ever-expanding knowledge base. This review provides: (1) a general overview of stem cells and MSCs in particular, (2) critically analyzes several cytokines known to alter MSC function, and (3) discusses methods to manipulate cytokine-activated MSCs to improve MSC function for potential clinical application.

Utilization of intravenous immunoglobulin to ameliorate alloantibodies in a highly sensitized patient with a cardiac assist device awaiting heart transplantation. Fluorescence-activated cell sorter analysis.

Surgery surrounding the use of mechanical assistance in cardiac transplant candidates often leads to multiple blood/platelet transfusions and subsequent development of alloantibodies. This is a case report of a 50-year-old male patient who had received blood transfusions during coronary bypass grafting 9 years earlier. He presented in acute and chronic heart failure and, despite therapy, became moribund with multisystem organ failure. His ejection fraction was 10%. A Novacor ventricular assist device was implanted on May 19, 1995 (day 0). The patient received 44 U of blood and 20 U of platelets. Although his percent reactive antibodies (PRA) were negative before surgery by fluorescence-activated cell sorter analysis, the PRA 3 days after implantation of the ventricular assist device was 80%; it increased to 100% by day 7. In an attempt to decrease the PRA, intravenous immunoglobulin was given at 3-week intervals. The PRA became negative and the patient received a donor heart that was negative by fluorescence-activated cell sorter cross-match on day 64. On days 69-72, a dramatic increase in alloantibody activity was promptly reversed with additional intravenous immunoglobulin. Currently at posttransplant month 12, the patient shows no humoral, cellular, or vascular evidence of rejection.

Early and late results of descending thoracic and thoracoabdominal aortic aneurysm open repair with deep hypothermia and circulatory arrest

OBJECTIVE Open repair of descending thoracic aortic and thoracoabdominal aortic aneurysms may carry low morbidity and mortality, depending on experience of the surgeon and operative technique used. Although thoracic endovascular aortic repair is less invasive, its limitations include anatomy and pathology of the aorta, proximity of major branches, and significant complication and reintervention rates. We retrospectively reviewed a 2-surgeon experience (J.W.F. and J.S.C.) with deep hypothermic circulatory arrest to repair descending thoracic aortic and thoracoabdominal aortic aneurysms. METHODS All patients (n = 343) who underwent surgical replacement of descending thoracic aortic or thoracoabdominal aortic aneurysm with deep hypothermic circulatory arrest from 1995 to 2009 were included. Segmental arteries between T8 and the celiac artery were aggressively reimplanted as indicated. Visceral and renal artery bypasses were performed for significant stenosis. Concomitant coronary artery bypass grafting was performed if targets were anterior or lateral wall vessels. Lumbar drains were not routinely used but placed postoperatively on clinical evidence of spinal cord ischemia. RESULTS Of 343 patients, 98 had descending thoracic aortic aneurysms, 69 had Crawford type I thoracoabdominal aortic aneurysms, 111 had type II, 32 had type III, and 33 had type IV. Emergency or urgent operations comprised 13% of repairs. Hospital mortalities were 5.0% for all cases, 3.7% for elective cases, and 13.3% for urgent or emergency cases. Overall incidences were 4.4% for stroke, 3.2% for paraplegia or paraparesis, 1.5% for renal failure requiring dialysis, and 3.5% for tracheostomy. The 1-, 3-, 5-, and 10-year survival rates were 90%, 79%, 69%, and 54%, respectively. CONCLUSIONS Surgical repair of descending thoracic aortic and thoracoabdominal aortic aneurysms with deep hypothermic circulatory arrest carries low operative morbidity and mortality and excellent early and late survival rates. These results can be used as a benchmark for future techniques and technologies.

One-stage segmental resection of extensive thoracoabdominal aneurysms with left-sided heart bypass.

PURPOSE The purpose of this study is to describe a technique for resection of extensive thoracoabdominal aneurysms, which the authors believe will lower morbidity and mortality rates. METHODS In an effort to minimize the risk of spinal cord ischemia, we have used a combination of sided heart bypass (left atrium to left femoral artery) with local cooling of the intercostal and visceral arteries and segmental resection of the aneurysm. Segmental resection of the aneurysm allows perfusion of the spinal cord and abdominal viscera as the proximal anastomosis is completed and as each pair of intercostal arteries is reimplanted. An attempt is made to reimplant all pairs of intercostal arteries from T8 to L2. Before the intercostal or visceral arteries are reimplanted, that segment of aorta is cooled with cold crystalloid solution. Thus no segment of the aorta is exposed to warm ischemia for more than 30 minutes. Left-sided heart bypass allows the patients temperature to be maintained between 35 degrees C and 37 degrees C. RESULTS We have used this technique in 23 patients with types I and II (Crawfords classification) thoracoabdominal aneurysms. Seven patients (30%) had dissections or rupture associated with their aneurysms and underwent emergency operation. One of these seven patients became paraplegic after operation, for a 4.3% incidence of paraplegia. One patient died of multiple organ failure after operation. No patient had kidney failure requiring dialysis. CONCLUSIONS We believe that our technique allows the operation to be performed in a deliberate manner with a low incidence of paraplegia and kidney failure.

Improved visualization of the internal mammary artery with a new retractor system

A new sternal retractor system was developed to improve exposure of the internal mammary artery and protect the lung. This retractor can be used for either single or bilateral dissection of the internal mammary artery. It has been used in more than 2,000 cases with excellent results.

Ruptured abdominal aortic aneurysms in a private hospital: a decade's experience (1980-1989).

Despite refinements in elective resection of abdominal aortic aneurysms, morbidity and mortality rates for ruptured abdominal aortic aneurysms (RAAAs) remain high. Between January 1, 1980 and December 31, 1989, we treated 208 patients with RAAAs whose mean age was 70 years. The overall mortality rate was 49.5%. Logistic regression analysis showed that three factors correlated with predicted patient survival. Patients <70 years old had a survival rate of 65.7% compared with a survival rate of 37.4% in patients >70 years old (p<0.001). Among “stable” patients (preoperative blood pressure consistently >90 mm Hg), 88.9% survived compared with 40.9% of “unstable” patients (blood pressure <90 mm Hg) (p<0.001). Of the patients with free intraperitoneal rupture, 38.3% survived compared with a survival rate of 79.6% of patients with rupture confined to the retroperitoneum (p<0.001). Despite a high overall mortality rate in patients with RAAAs, surgical intervention remains the only hope for survival. We continue to advocate an aggressive surgical approach in this group of patients.