Leonard L. Bailey

Facile Minimally Invasive Cardiac Surgery via Ministernotomy

BACKGROUNDnThe publics and surgeons perception of minimally invasive operations are frequently at odds. Nevertheless, real or perceived benefits may result from limiting skin and skeletal trauma.nnnMETHODSnBeginning in January 1996, we began approaching most infant and pediatric open heart procedures through an upper sternal split incision using a 1- to 3-inch skin opening and then extended this technique using a 2.5- to 3.5-inch incision for adult aortic and mitral valve replacement.nnnRESULTSnA total of 82 patients, 57 infants and children and 25 adults, have been operated on using this approach (age range, newborn to 81 years). Operations accomplished through ministernotomy have included aortic valvotomy, arterial switch, tetralogy of Fallot, atrial or ventricular septal defect closure, aortic valve replacement, mitral valve replacement and repair, redo aortic or mitral valve replacement, double valve replacement, aortic root replacement, and complex arch reconstruction. In adults, the sternum was divided and then a T incision was made at the second, third, or fourth intercostal space. The mitral valve was reached through the roof of the left atrium. In children, a lower sternal split was used for atrial septal defect repairs. All cannulas were introduced through the ministernotomy incision, eliminating femoral cannulation. No new instruments, retractors, or ports were used. Mediastinal drainage was accomplished through a Blake drain connected to Heimlich-valved grenade suction. All but 2 patients were extubated immediately. Hospital stay was from 1 to 20 days (median 2 days). Patient and family acceptance is very high.nnnCONCLUSIONSnOn the basis of this initial experience, we attempt all congenital cardiac and isolated adult valve operations through ministernotomy.

Ultra fast track in elective congenital cardiac surgery

BACKGROUNDnChanges in healthcare delivery have affected the practice of congenital cardiac surgery. We recently developed a strategy of limited sternotomy, early extubation, and very early discharge, and reviewed the perioperative course of 198 pediatric patients undergoing elective cardiovascular surgical procedures, to assess the efficacy and safety of this approach.nnnMETHODSnOne hundred ninety-eight patients aged 0 to 18 years (median 3.2 years) underwent 201 elective cardiovascular surgical procedures over a 1-year period. All patients were admitted on the day of surgery. Patients were divided into six diagnostic groups: group 1, complex left-to-right shunts (n = 14, 7.0%); group 2, simple left-to-right shunts (n = 83, 41.3%); group 3, right-to-left shunts with pulmonary obstruction (n = 33, 16.4%); group 4, isolated, nonvalvular obstructive lesions (n = 30, 14.9%); group 5, isolated valvular anomalies (n = 20, 10.0%); and group 6, miscellaneous (n = 21, 10.4%).nnnRESULTSnAfter 201 procedures, 175 patients (87.1%) were extubated in the operating room and 188 (93.6%) within 4 hours from operation. Four patients (2.0%) were extubated more than 24 hours from completion of the procedure, and 2 (1.0%) died while on respiratory support (never weaned). Five patients (2.6%) failed early extubation (<4 hours). Early discharge was achieved for the vast majority of patients. Overall median length of stay (LOS, including day of surgery as day 1) was 2.0 days, with a median LOS of 3.0 days for those patients requiring circulatory arrest duration exceeding 20 minutes. Of 195 patients, 43 (24.6%), 121 (74.0%), and 159 (81.5%) were discharged, respectively, at <24, <48, <72 hours from admission. Longest and shortest mean postoperative LOS were in group 6 (9.9+/-14.5 days) and group 2 (1.6 = 0.7 days), respectively. Six patients (2.9%) died, and 11 (5.5%) suffered in-hospital complications. Thirty patients (15.4%) were either treated as outpatients (n = 11, 5.7%) or readmitted (n = 19, 9.7%) within 30 days from the time of surgery. Only 8 of 195 patients (4.1%) were readmitted with true surgical complications requiring invasive therapeutic procedures.nnnCONCLUSIONSnSelected patients with a broad spectrum of congenital heart disease may enjoy same-day admission, limited sternotomy, immediate extubation, and very early discharge with excellent outcomes and acceptable morbidity.

Cardiac transplantation in infancy: Donors and recipients

To evaluate the role of orthotopic cardiac transplantation for infants with lethal cardiac disease, we revlewed the results from our first 25 patients. Data on the donors were also reviewed to define the characteristics of a successful cardiac donor. Patients had transplants between November 1985 and November 1988. Several primary cardiac diagnoses were indications for transplantation, including congestive cardiomyopathy, hypoplastic left-heart syndrome, and other types of native and postoperative complex congenltal heart diseases. The ages ranged from birth to 7 months. Of 25 patients, 21 are still allve (84% survival rate) with follow-up from 4 to 40 months. No late deaths have occurred. Long-term immunosuppression was accomplished with cyclosporine and azathioprine. Rejection surveillance was performed noninvasively; only one child required an endomyocardial biopsy. Donors died from a variety of traumatic and metabolic causes, including sudden infant death syndrome. The majority (72%) of donors had a history of cardiac arrest requiring cardiopulmonary resuscltation. One third were receiving inotropic support at the time of cardiac evaluation. We conclude that orthotopic cardiac transplantation is an effective therapy for infants with lethal heart disease. A larger donor pool is required, and many dying infants, despite cardiac arrest and resuscitation, would be suitable donors.

Successful transplantation of hearts harvested 30 minutes after death from exsanguination

The donor pool for heart transplants is severely limited. Unfortunately, many trauma patients who might be donors die of exsanguination before their organs can be used. We tested whether hearts dead for one half hour after exsanguination could be used as heart transplants in 8 lambs (mean weight, 8 kg). Four lambs were exsanguinated by severing the subclavian artery while simultaneously infusing intravenous saline solution to mimic resuscitation attempts. All animals died. Thirty minutes after hypotensive arrest and death, simulating the time needed to secure donation permission, the heart was harvested, perfused with 250 mL of cold cardioplegia containing 200,000 units of streptokinase to dissolve intravascular clots, and stored in iced saline solution for a mean of 1.5 hours while 4 recipient lambs were prepared for operation. After bypass and recipient heart excision, the dead donor heart was transplanted orthotopically. The heart was reperfused with low flow (25 mL/min), low pressure (30 mm Hg), low hematocrit (hematocrit, 0.08 to 0.12) blood supplemented with prostaglandin E1 and nifedipine for 15 minutes, followed by full flow rewarming for 45 minutes. All hearts resumed normal contractions. All animals were weaned from bypass without inotropes. Pressures a half hour after bypass were (in mm Hg): aorta, 80 +/- 10; pulmonary artery, 20 +/- 5; right atrium, 9 +/- 5; and left atrium, 9 +/- 2. We conclude that hearts dead for one half hour after exsanguination are capable of being reanimated and used successfully as donor organs. With further development, this method could potentially greatly expand the donor heart pool.

Neurologic sequelae of deep hypothermic circulatory arrest in cardiac transplant infants

BACKGROUNDnConsiderable controversy exists experimentally and clinically regarding adverse neurologic effects that may follow deep hypothermic circulatory arrest. Moreover, the techniques of DHCA have never been standardized.nnnMETHODSnWe prospectively studies the neurodevelopmental outcome in 38 infants undergoing cardiac transplantation using DHCA before the age of 4 months (mean age, 37.0 days). Neurodevelopmental outcome in the 22 boys and 16 girls was tested up to 2.5 years after transplantation using Bayley scale of infant development. Bayley scores were compared with the rate of core cooling and the length of DHCA in all patients. Deep hypothermic circulatory arrest was accomplished using an asanguineous prime resulting in hematocrits of 5% +/- 5% and ionized Ca2+, 0.4 +/- 0.1 mmol/L. No surface precooling was used, but the head was packed in ice. Mean cooling time was 14.0 +/- 3.5 minutes, resulting in rectal temperatures of 18 degrees +/- 2.5 degrees C. Duration of DHCA ranged from 42 to 70 minutes (mean duration, 56.0 +/- 6.6 minutes).nnnRESULTSnPostoperatively, the mean Bayley psychomotor development index was 91 (range, 50 to 130) and mental development index was 88 (range, 50 to 130). No relationship was found between either the rate of cooling or the duration of DHCA and Bayley scores (r = 0.227 and r = 0.322, respectively).nnnCONCLUSIONSnThese data suggest that neither the rate of cooling nor DHCA times between 42 and 70 minutes using profoundly low hematocrits and low ionized calcium levels has any measurable effect on neurologic outcome up to 2.5 years postoperatively. It is possible that adverse neurologic outcomes from DHCA reflect particular methods of achieving DHCA.

Facile retrograde cardioplegia: Transatrial cannulation of the coronary sinus

The benefits of coronary sinus (CS) cardioplegia are well known, yet CS cardioplegia is not used widely owing to the need for bicaval cannulation, snares, and an atriotomy. We designed and used in 225 consecutive patients a catheter containing a flexible removable stylet that, when shaped into a hockey-stick configuration, enabled blind intubation of the CS through a small pursestring in the right atrium, guided easily into the CS using a finger on the atrioventricular groove at the inferior vena cava. The CS was intubated in all patients; a pressure-limited balloon at the catheter tip was inflated after cross-clamping. An integral distal pressure line measured CS pressure. Catheters were placed distally within the great cardiac vein beyond the posterior interventricular vein; the position did not alter cooling: right ventricular free wall, septum, and left ventricular free wall temperatures were 7 degrees +/- 2 degrees, 8 degrees +/- 2 degrees, and 7 degrees +/- 2 degrees C, respectively, after an initial 10 mL/kg of blood cardioplegia. Transatrial CS cardioplegia was used in 45 aortic valve replacements, 22 mitral valve replacements, 4 triple-valve replacements, 6 congenital lesions, and 148 coronary revascularizations, including 40 redo operations. Atheromatous material was routinely flushed retrogradely from cut old vein grafts during revascularization; 70 revascularizations (47%) were performed urgently for acute infarction or jeopardized myocardium. No heart block or CS injury occurred, and inotrope use dropped to 10% of patients (from 38% in the previous 256 patients with antegrade blood cardioplegia). We conclude that the CS can be cannulated transatrially and that CS cardioplegia is more facile than antegrade cardioplegia.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric cardiac retransplantation: Intermediate-term results

BACKGROUNDnCardiac retransplantation (re-CTx) in children is a controversial therapy, yet it remains the best treatment option to recipients with failing grafts. Our objective was to determine the incidence of re-CTx in a large pediatric population of recipients and evaluate the outcome of such therapy.nnnMETHODSnBetween November 1985 and November 1999, 347 children underwent cardiac transplantation at the Loma Linda University Medical Center. Of these, 32 children were listed for re-CTx. Ten patients died while waiting, and 22 recipients underwent re-CTx. Median age at re-CTx was 7.1 years (range, 52 days to 20.1 years).nnnRESULTSnIndications for re-CTx were allograft vasculopathy (n = 16), primary graft failure (n = 5), and acute rejection (n = 1). Two patients with primary graft failure underwent retransplantation within 24 hours of the first transplantation procedure while on extracorporeal membrane oxygenation support. Median time interval to re-CTx for the others was 7.2 years (range, 32 days to 9.4 years). Operative mortality for all cardiac re-CTx procedures was 13.6%. Causes of hospital mortality were pulmonary hypertension with graft failure (n = 2) and multiorgan failure (n = 1). Median hospital stay after re-CTx was 14.1 days (range, 6 to 45 days). There was one late death from severe rejection. Actuarial survival at 3 years for re-CTx was 81.9% +/- 8.9% compared with 77.3% +/- 2.6% for primary cardiac transplantation recipients (p = 0.70).nnnCONCLUSIONSnElective re-CTx can be performed with acceptable mortality. Although the number of patients undergoing retransplantation in this report is small and their long-term outcome is unknown, the intermediate-term survival after re-CTx is similar to that of children undergoing primary cardiac transplantation.

Pericardioperitoneal shunt: An alternative treatment for malignant pericardial effusion

The treatment of 37 consecutive cases of symptomatic malignant pericardial effusion over a period of 13 years was retrospectively analyzed. The most common diagnoses were lung cancer (59%) and breast cancer (11%). In the most recent 4 patients, the Denver pleuroperitoneal shunt was used to drain the pericardial effusion into the peritoneal cavity. In each case, the procedure was performed under local anesthesia, and the patient was discharged 2 to 4 days later without complications. Three of the patients subsequently died of the disease process without evidence of cardiac failure or tamponade during 6-month follow-up. The more traditional means of pericardial drainage, the subxiphoid approach (14 patients) and the anterior thoracotomy approach (19 patients), were associated with higher postoperative morbidity (21% and 53%, respectively) and mortality (7% and 42%, respectively). Because of the small number of patients treated by pericardioperitoneal shunting, a significant difference was demonstrated only in the length of hospital stay (shunt, 2.8 +/- 0.5 days; subxiphoid, 11.2 +/- 4.6 days; thoracotomy, 14.9 +/- 6.1 days). Median survivals were essentially the same (shunt, 3.5 months; subxiphoid, 2.7 months; thoracotomy, 1.2 months). It is apparent that the pericardioperitoneal shunt, although a much simpler procedure, can accomplish similar palliation effectively in the treatment of malignant pericardial effusion.

Bypass coaptation procedures for cervical nerve root avulsion.

In the past, patients with cervical spinal nerve root avulsions were resigned to accept a natural crippling from upper extremity neurological deficits. Recently, bypass coaptation procedures have resulted in functional return of denervated muscles after such avulsions, much to the appreciation of patients. Presented are 12 patients with avulsion of cervical spinal nerve roots that form either the brachial plexus upper trunk (n = 7), lower trunk (n = 1), or all three trunks (n = 4). The patients underwent the new bypass coaptation procedures with complete or partial return of motor and sensory function, which otherwise would be totally nonfunctional. The most dramatic results were noted in those patients who underwent operations within 6 weeks of injury. The results of these procedures offer patients a valid therapeutic modality for an enhanced quality of life after cervical nerve root avulsion.

Male donor into female recipient increases the risk of pediatric heart allograft rejection

Sixty-one infants and children, 12 years old or younger, who received an orthotopic cardiac allograft between November 1985 and December 1989 were analyzed for the incidence of rejection. Rejection was diagnosed non-invasively within the first 3 months and during the first year. Rejection episodes were diagnosed by signs and symptoms according to previously reported criteria. Multiple regression analysis with recipient age, donor age, donor-recipient weight ratio, number of HLA mismatches, sex of the recipient, sex-encoded minor tissue antigen incompatibility (H-Y: female recipients receiving male donor organ), graft ischemic time, lowest cyclosporine level during the first 2 postoperative weeks, and prophylactic use of OKT3 showed that H-Y was the only significant contributing factor for rejection at 3 months and 1 year (r = 0.308, p < 0.02; r = 0.308, p < 0.02; respectively). Patients were divided into two groups: group 1, 45 patients who were H-Y compatible (male and female recipients receiving female donor hearts); and group 2, 16 patients who were H-Y incompatible (female recipients with male hearts). Patients in group 2 had significantly more episodes of graft rejection than did patients in group 1 by 3 months and by 12 months after heart transplantation (3 months: 2.75 +/- 1.48 versus 1.67 +/- 1.41, p < 0.05; 1 year: 4.80 +/- 1.87 versus 2.59 +/- 1.93, p < 0.01; respectively). There were six grafts lost due to rejection in group 2 (6/15, 37.5%) and 7 grafts lost (7/45, 15.5%) in Group 1 (not significant). Heart transplantation with H-Y incompatibility resulted in a significantly greater incidence of rejection episodes.