Michael Desmond

A prospective randomised study of continuous warm versus intermittent cold blood cardioplegia for coronary artery surgery: preliminary report.

Between October 1991 and March 1993, 281 consecutive patients underwent non-emergency isolated coronary artery surgery under the care of one surgeon (A.R.). They were prospectively randomised to receive either intermittent cold (Group I-144 patients) or continuous warm (Group II-137 patients) blood cardioplegia for myocardial protection. There were no significant differences in clinical outcome between the two groups, as judged by operative mortality, rates of peri-operative myocardial infarction, blood loss, need for circulatory support, post-operative neurological deficit, or duration of intensive care or hospital stay. However, sinus rhythm returned spontaneously with greater frequency (91.2% vs 45.8%, P < 0.001) in Group II patients. There was greater transmyocardial oxidative stress in Group I patients, as evidenced by a significant rise in oxidised glutathione in coronary sinus blood on myocardial reperfusion. Also, the serum CKMb isoenzyme level 2 h post-operatively was significantly raised in Group I patients, although this difference had disappeared by the day after surgery. In conclusion this preliminary report suggests that continuous warm blood cardioplegia provides comparable myocardial protection to that achieved with standard hypothermic techniques in patients undergoing coronary artery surgery.

Continuous warm versus intermittent cold blood cardioplegia for coronary bypass surgery in patients with left ventricular dysfunction

Between October 1991 and March 1994, 108 consecutive patients with moderate to severe left ventricular dysfunction underwent non-emergency isolated coronary artery surgery under the care of one surgeon (A.R.). They were prospectively randomised to receiving either intermittent cold (Group 1-50 patients) or continuous warm (Group 2-58 patients) blood cardioplegia for myocardial protection. There were no significant differences in clinical outcome between the two groups, as judged by operative mortality, rates of perioperative myocardial infarction, the serum CKMB isoenzyme level at 2 and 18 h after operation, need for circulatory support, postoperative neurological deficit, or duration of hospital stay. Group 2 patients required significantly more potassium (68 vs 29 mmol, P < 0.001) to maintain diastolic arrest and also had higher serum potassium levels after removal of the cross-clamp (P < 0.001). However, sinus rhythm returned spontaneously with greater frequency (91.2% vs 45.8%, P < 0.001) in Group 2 patients. In conclusion this report suggests that retrograde continuous warm blood cardioplegia provides comparable myocardial protection to that achieved with retrograde intermittent cold blood cardioplegia in patients with moderate to severe left ventricular dysfunction undergoing isolated coronary artery surgery.

Mitral Valve Involvement in Wegener's Granulomatosis

Wegeners granulomatosis is an autoimmune condition resulting in the granulomatous vasculitis of small-to-medium-sized vessels, and is characterized by granulomatous lesions in the renal and respiratory systems. Cardiac involvement in Wegeners granulomatosis has been previously reported. However, involvement of cardiac valves is extremely rare. We present a patient with Wegeners granulomatosis with an extensive mitral mass extending to the aortic valve.

True Aneurysm of a Dacron Tube Graft 19 Years After Repair of Coarctation of the Aorta

We report a 31-year old woman who presented with acute onset of shortness of breath 19 years after multiple repairs of a preductal coarctation of the aorta using a Dacron tube graft. Imaging studies showed an aneurysm had developed in the tube graft. The aneurysmal tube graft was replaced during an open repair.

Blunt Aortic Injury Secondary to Fragmented Tenth Thoracic Vertebral Body

We present a case of blunt traumatic aortic laceration following a motor vehicle crash. The aortic laceration was 4.5 cm above the coeliac axis and occurred because of an unstable tenth thoracic vertebral body. Open surgery was considered high risk, whereas an endovascular approach with an endoprosthesis placed at the exact anatomic location of the laceration was advocated.

Cerebral protection in hemi-aortic arch surgery

Surgical therapy for aortic arch disease usually requires a period of hypothermic circulatory arrest, which calls for cerebral protection strategies and adjuncts. The optimal strategy for protecting the brain from irreversible ischaemic damage during the period of circulatory arrest remains controversial. Patients present with diverse aortic pathologies and this may dictate different cerebral protection methods that are tailored for the circumstances of each individual case. The purpose of this overview is to describe each method of cerebral protection employed in hemi-aortic arch surgery and to explain their advantages and disadvantages. A surgical case on hemi-aortic arch replacement using retrograde cerebral perfusion is demonstrated (Video 1). We also present our hospital demographics and outcomes pertaining to cerebral protection in hemi-aortic arch surgery. Video 1 Cerebral protection in hemi-aortic arch surgery The current practices employed for brain protection during aortic arch surgery include: (I) deep hypothermic circulatory arrest (DHCA); (II) retrograde cerebral perfusion (RCP); and (III) selective antegrade cerebral perfusion (SACP).

Avoiding the use of helmet continuous positive airway pressure after surgery on thoracic aorta

Spinal cord ischaemia remains a major problem after surgery of the thoracic aorta. Early detection and avoidance of systemic hypotension can prevent permanent neurological damage. We report a rare case that developed a temporary paraplegia postoperatively, associated with the use of helmet continuous positive airway pressure.

Successful reversal of delayed paraplegia associated with chronic type A aortic dissection using a spinal drain.

Delayed neurological deficit (DND) following thoracic and thoracoabdominal aortic aneurysm repair refers to any neurological deficit in a patient who is evaluated to be neurologically intact postoperatively, but develops neurological problems several hours or days later which can be reversed if identified and treated immediately. We report a rare case where cerebrospinal fluid drainage reversed DND that happened 18 months following type A dissection repair.

Liverpool Aortic Surgery Symposium V: New Frontiers in Aortic Disease and Surgery

Aortic aneurysm disease is a complex condition that requires a multidisciplinary approach in management. The innovation and collaboration among vascular surgery, cardiothoracic surgery, interventional radiology, and other related specialties is essential for progress in the management of aortic aneurysms. The Fifth Liverpool Aortic Surgery Symposium that was held in May 2013 aimed at bringing national and international experts from across the United Kingdom and the globe to deliver their thoughts, applications, and advances in aortic and vascular surgery. In this report, we present a selected short synopsis of the key topics presented at this symposium.

A Single-Stage Repair of Arch and Descending Thoracic Aortic Aneurysms Using Jotec E-vita Open Plus Hybrid Stent Graft Combined With Antegrade Deployment of Thoracic Endograft

We report a unique case of a 63-year-old female with extensive peripheral vascular disease who underwent a single-stage surgical repair of the aortic arch and descending thoracic aortic aneurysm utilizing the Jotec E-vita Open Plus hybrid stent graft system combined with antegrade deployment of a thoracic endograft via a median sternotomy.