Myles E. Lee

Intraoperative Doppler color flow mapping for assessment of valve repair for mitral regurgitation

The ability of color Doppler flow mapping to provide intraoperative information about mitral regurgitation (MR) severity and to evaluate adequacy of mitral valve repair was assessed by performing color Doppler echocardiography immediately before and after cardiopulmonary bypass, with the transducer placed directly on the epicardium. In 56 patients, the degree of MR by intraoperative color Doppler correlated well with left ventricular angiography (kappa = 0.80) and with closed-chest preoperative color Doppler (kappa = 0.84) and had good interobserver reproducibility (kappa = 0.88). Good correlation was also seen between closed-chest color Doppler and angiography (kappa = 0.75). After mitral valve repair in 18 patients (15 ischemic MR, 3 cleft valves), color Doppler was used to assess severity of residual MR intraoperatively and postoperatively. Intraoperative color Doppler identified satisfactory repair (MR less than or equal to 2+) in 15 patients and failure (MR greater than or equal to 3+) in 3, whereas conventional surgical assessment of MR by fluid filling of the arrested ventricle failed to provide reliable differentiation. MR severity on subsequent closed-chest color Doppler follow-up did not change significantly compared with intraoperative evaluation after repair. Intraoperative color Doppler provides accurate grading of MR severity, offers instantaneous evaluation of the adequacy of mitral valve repair before chest closure, and appears to predict the degree of postoperative MR seen on subsequent closed-chest follow-up studies.

Combined Valve and Coronary Artery Bypass Procedures in Septuagenarians and Octogenarians: Results in 120 Patients

A consecutive series of 96 septuagenarians (mean age, 74) and 24 octogenarians (mean age, 83) underwent coronary artery bypass (CAB) and valve operations using hypothermia and hyperkalemic cardioplegia in a 45-month period; there was a mean of 2.6 grafts per patient. Most patients were in New York Heart Association (NYHA) class IV (57% of the septuagenarians and 88% of the octogenarians) preoperatively. The early deaths were 19% for septuagenarians and 37% for octogenarians; late deaths were 9% and 6%, respectively, after a mean of 25 months. Of 92 survivors, 78% of the septuagenarians and 87% of the octogenarians improved by one or more NYHA class postoperatively. Of 58 patients with combined CAB and aortic valve replacement, 12 (21%) died; of 38 with combined CAB and mitral valve replacement 19 (50%) died; 2 of 9 (22%) with combined CAB and double valve replacement died; and 2 of 11 (18%) with CAB and MV repair died. In comparison, of patients with isolated valve replacement in the same period, 2 of 30 (7%) in the AVR group died, 5 of 17 (29%) died in the MVR group, 2 of 7 (33%) in the DVR group died. The risk of combined valve procedures and bypass surgery was significantly increased in the elderly and may warrant a less aggressive procedure, especially in the mitral position.

CK-MB Release Following Coronary Artery Bypass Grafting in the Absence of Myocardial Infarction

Elevation of levels of the myocardial-specific isoenzyme of creatine kinase (CK-MB) in the immediate postoperative period in patients undergoing coronary artery bypass grafting is usually associated with myocardial necrosis. However, mean isoenzyme elevations of 18 +/- 2 IU/L (standard error of the mean) were recently observed in 6 patients in the absence of electrocardiographic or scintigraphic (technetium 99m stannous pyrophosphate) evidence of perioperative myocardial infarction. To test the hypothesis that surgical trauma of the atrium and aorta during cannulation for cardiopulmonary bypass might contribute to elevated CK-MB levels, biopsy of the right atrial appendage and aorta of 7 patients was done at operation, the tissue samples were assayed for total creatine kinase (CK) activity using the Rosalki technique, and for CK-MB using column chromatography. The results indicate that the human atrium is a rich source of CK, with the proportion of CK-MB similar to that present in the ventricle (20%). In addition, technical considerations inherent in the performance of coronary bypass surgery may result in release of CK-MB, causing elevated serum enzyme levels in the post-coronary artery bypass patient in the absence of myocardial infarction.

Special Considerations in Ventricular Pacing in Patients with Tricuspid Valve Disease

In patients who have undergone prosthetic tricuspid valve replacement or tricuspid annuloplasty and in whom the pericardial space is obliterated by adhesions from previous operations, the need for ventricular pacing may be met by lead placement in the venous tributaries of the coronary veins. This approach avoids compromise of prosthetic tricuspid valve function and injury to bioprosthetic valves and natural valves repaired by annuloplasty. Although acute stimulation thresholds are slightly higher than those for short-term endocardial implants, stable long-term ventricular pacing has been observed in patients reported in the literature in whom such lead placement was inadvertent and in the 2 patients in the present paper in whom such replacement was deliberate. This method appears to be a safe alternative to standard ventricular pacing techniques under the special circumstances reported here.

Curvilinear paramedian sternotomy

A modification of the classic straight midline sternotomy incision is described. The technique involves performing the sternotomy in a curvilinear manner along both sides of the midline to create two sternal halves that interdigitate with one another. With such a configuration, malalignment is virtually impossible.

Pneumoperitoneum complicating coronary bypass surgery: management without laparotomy

SummaryDrainage of the mediastinum or thoracic cavity following bypass surgery is a routine procedure. A case is reported where pneumoperitoneum developed after the surgical procedure with vague abdominal symptoms accompanied by fever and leukocytosis. Because of the possibility of a rupture of an intra-abdominal organ laparoscopy was performed in this very ill patient and laparotomy avoided. Attention is drawn to this particular group of patients with the sequela of pneumoperitoneum in which laparoscopy can solve the diagnostic dilemma.

Pulmonary Artery Balloon Counterpulsation

6. Poirier RA, McGoon DC, Danielson GK, et al: Late results after repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 73:900, 1977 Truster V, McGoon DC, Kennedy MA, et al: Long term evaluation (12-22 years) of open heart surgery for tetralogy of Fallot. Am J Cardiol 46:635, 1980 Ilbawi MN, ldriss FS, Muster A], et al: Tetralogy of Fallot with absent pulmonary valve. J Thorac Cardiovasc Surg 81:906, 1981 Dunnigan A, Oldham HN, Benson DW: Absent pulmonary valve syndrome in infancy: Surgery reconsidered. Am J Cardiol 48:117, 1981 Abduleh SA, Silverton NP, Yakirevich VS, Ionescu MI: Right ventricular outflow tract reconstruction with a bovine pericardial monocusp patch. J Thorac Cardiovasc Surg 89:761, 1985 Arciniegas E: Tetralogy of Fallot. In Arciniegas E (ed): Pediatric Cardiac Surgery. Chicago, Year Book Medical Publishers, 1985, p 211

Digital injury using the sternum perforating awl.

Closure of the median sternotomy incision using stainless steel wires passed through the tip of a sternum-perforating awl is a common procedure. Digital injury can result should the awl shaft suddenly snap during sternal penetration. Sheathing the shaft with a plastic guard will prevent injury when this occurs.