Paul H. Werner

Open versus endoscopic saphenous vein harvesting: wound complications and vein quality

BACKGROUND The saphenous vein is an important conduit for coronary artery bypass grafting. Wound complications from traditional open vein harvesting occur often. Minimally invasive endoscopic saphenous vein harvesting may decrease wound complications. Vein quality may be an issue with endoscopic harvesting. METHODS We reviewed 568 patients who had bypass grafting and saphenous vein harvesting either endoscopic (group A, n = 180) versus open (group B, n = 388). Both groups were demographically similar and management identical. Wound complication was defined by the need for intervention and included lymphocele, hematoma, cellulitis, edema, eschar, and infection. Multiple vein segments were obtained from 8 patients, 4 from each group, and examined histologically. RESULTS Wound complications were significantly less in group A (9/180, 5%) versus group B (55/388, 14.2%), p value equal to or less than 0.001. Open harvesting (p< or =0.001), diabetes (p< or =0.001), and obesity (p< or =0.02) were risk factors for wound complication by univariate analysis. By multiple logistic analysis, open harvesting (p< or = 0.0007) and diabetes (p< or =0.0001) were independent risk factors for wound infection. Histologic evaluation of vein samples showed that there was no difference between the groups and vascular structural integrity was maintained. CONCLUSIONS Endoscopic saphenous vein harvesting was associated with fewer wound complications and infections. Vein quality was not adversely effected because of endoscopic harvesting.

Results of Intraaortic Balloon Pumping after Cardiac Surgery: Experience with the Percor Balloon Catheter

One hundred thirty-eight patients undergoing an open-heart procedure required an intraaortic balloon pump (IAPB) postoperatively. In Group I (N = 45), the AVCO femoral conduit surgical technique was used; in Group II (N = 93), the Percor balloon was inserted either in the operating room after groin cutdown (open insertion) or percutaneously in the intensive care unit (percutaneous insertion). IABP usage increased in Group II (3% versus 1.6%; p less than 0.001). Immediate mortality was 40% (55/138). Use of the Percor balloon in Group II resulted in lower immediate mortality (32/93 or 34% versus 23/45 or 51%; p less than 0.06). Delayed mortality from multiorgan failure was 11.6% (16/138). Immediate percutaneous insertion at the bedside rather than a return to the operating room for open insertion yielded lower mortality (2/8 or 25% versus 6/7 or 86%; p less than 0.05). Open insertion of the Percor balloon decreases the failure rate of insertion compared with both the AVCO femoral conduit technique (7/85 or 8.2% versus 5/45 or 11%) and percutaneous insertion. It has more complications than the AVCO femoral conduit technique (7/85 or 8.2% versus 2/45 or 4.4%) and less than percutaneous insertion.

Vasodilator effects of the sodium acetate in pooled protein fraction.

Paradoxical hypotension during rapid infusion of plasma protein fraction (PPF) has been attributed to yasodilation by bradykinin in PPF. This study employed a canine, controlled right heart bypass preparation to assess changes in systemic vascular resistance and venous capacitance during infusion of PPF and other possibly vasoactive mediators. Plasma protein fraction caused consistent vasodilation, whereas purified human albumin did not. This vasodilation could be ascribed entirely to acetate, present in PPF as a buffer. Bradykinin in PPF had no effect during venous infusion. Acetate is used widely as a buffer in intravenous and dialysate solutions. Its vasoactive properties must be recognized when such solutions are administered to patients with limited capacity to compensate for sudden vasodilation.

Improved Early Results After Aortic Valve Replacement: Analysis by Surgical Time Frame

Primary aortic valve replacement was performed in 430 patients. It was an isolated procedure in 339 and was combined with coronary artery bypass grafting in 91. Of these patients, 282 underwent operation from 1970 through 1976 (time frame 1) and 148 from 1980 through 1985 (time frame 2). They were divided into subgroups by age, New York Heart Association functional class, combined coronary artery bypass graft, and valvular lesion. Overall hospital mortality was 7.7% (time frame 1 = 10.6% versus time frame 2 = 2.0%; p less than 0.01). Overall, functional class III or IV was the strongest predictor of hospital mortality (p less than 0.001). Association of coronary artery bypass graft was the next strongest predictor of hospital mortality (p less than 0.01), and it retained its predictive value in time frame 2. Overall, hospital mortality was higher in patients older than 55 years (10.5% versus 3.5%; p less than 0.05). There were no hospital deaths in patients younger than 55 years in time frame 2. Type of valvular lesion was not a predictor of hospital mortality. Hospital mortality in patients receiving cardioplegia was 2%. Cardioplegia use has lessened the effect of age and functional class as predictors of hospital mortality after primary aortic valve replacement. Earlier operation in time frame 2 played a substantial role in the overall improvement of early results.

Life-threatening Chylothorax after Left Internal Mammary Artery Dissection: Therapeutic Considerations

Persistent chylothorax developed in a 53-year-old man after left internal mammary artery (LIMA) takedown and required surgical intervention. After an unsuccessful supraclavicular approach, left-sided standard thoracotomy showed thick adhesions around the LIMA takeoff with a diffuse oozing rather than an identifiable discrete leak. A possible leaking point was stitched, the area was sealed with fibrin adhesive, and complete remission ensued. Operation for chylothorax after LIMA takedown is challenging. A left-sided standard thoracotomy with minimal dissection and use of fibrin adhesive rather than blind stitching are recommended.

Successful treatment of post-mitral valve annuloplasty aspergillus flavus endocarditis

Aspergillus endocarditis is associated with a very high mortality. Of approximately 67 cases reported in the English language literature, there have been only two known survivors. This report describes a patient with Aspergillus flavus endocarditis after mitral valve annuloplasty who recovered with combined surgical and antifungal therapy. This is the first successfully treated case due to A. flavus and the first involving an annuloplasty ring.

Enhanced store-operated Ca2+ influx and ORAI1 expression in ventricular fibroblasts from human failing heart

ABSTRACT Excessive cardiac fibrosis, characterized by increased collagen-rich extracellular matrix (ECM) deposition, is a major predisposing factor for mechanical and electrical dysfunction in heart failure (HF). The human ventricular fibroblast (hVF) remodeling mechanisms that cause excessive collagen deposition in HF are unclear, although reports suggest a role for intracellular free Ca2+ in fibrosis. Therefore, we determined the association of differences in cellular Ca2+ dynamics and collagen secretion/deposition between hVFs from failing and normal (control) hearts. Histology of left ventricle sections (Masson trichrome) confirmed excessive fibrosis in HF versus normal. In vitro, hVFs from HF showed increased secretion/deposition of soluble collagen in 48 h of culture compared with control [85.9±7.4 µg/106 cells vs 58.5±8.8 µg/106 cells, P<0.05; (Sircol™ assay)]. However, collagen gene expressions (COL1A1 and COL1A2; RT-PCR) were not different. Ca2+ imaging (fluo-3) of isolated hVFs showed no difference in the thapsigargin-induced intracellular Ca2+ release capacity (control 16±1.4% vs HF 17±1.1%); however, Ca2+ influx via store-operated Ca2+ entry/Ca2+ release-activated channels (SOCE/CRAC) was significantly (P≤0.05) greater in HF-hVFs (47±3%) compared with non-failing (35±5%). Immunoblotting for ICRAC channel components showed increased ORAI1 expression in HF-hVFs compared with normal without any difference in STIM1 expression. The Pearsons correlation coefficient for co-localization of STIM1/ORAI1 was significantly (P<0.01) greater in HF (0.5±0.01) than control (0.4±0.01) hVFs. The increase in collagen secretion of HF versus control hVFs was eliminated by incubation of hVFs with YM58483 (10 µM), a selective ICRAC inhibitor, for 48 h (66.78±5.87 µg/106 cells vs 55.81±7.09 µg/106 cells, P=0.27). In conclusion, hVFs from HF have increased collagen secretion capacity versus non-failing hearts and this is related to increase in Ca2+ entry via SOCE and enhanced expression of ORAI, the pore-forming subunit. Therapeutic inhibition of SOCE may reduce the progression of cardiac fibrosis/HF. Summary: The excessive collagen secretory phenotype found in failing human hearts is associated with ventricular fibroblast remodeling, caused by an elevated influx of intracellular calcium via SOC channels.

Circulating biomarkers predictive of postoperative atrial fibrillation

Postoperative atrial fibrillation (PoAF), a common complication of cardiac surgery, contributes significantly to morbidity, mortality, and increasing healthcare costs. Despite advances in surgical and medical management, the overall incidence of PoAF has not changed significantly, partly because of the limited understanding of mechanisms underlying acute surgery-related factors, such as myocardial injury, inflammation, sympathetic activation, and oxidative stress, which play an important role in the initiation of PoAF, whereas a preexisting atrial substrate appears to be more important in the maintenance of this dysrhythmia. Thus, in a majority of patients, PoAF becomes a manifestation of an underlying arrhythmogenic substrate that is unmasked after acute surgical stress. As such, the ability to identify which patients have this proarrhythmic substrate and are, therefore, at high risk for developing AF postoperatively, is important for the improved selection for prophylactic interventions, closer monitoring for complications, and establishing the probability of AF in the long term. This review highlights the role of the underlying substrate in promoting PoAF, proposed mechanisms, and the potential role of serum biomarkers to identify patients at risk for PoAF.

Cardiomyoplasty after implantation of a pacemaker and cardioverter/defibrillator☆

Presently, a combination of two surgical methods improves the survival of patients with advanced ventricular dysfunction: implantable cardioverter/defibrillator implantation (which prevents sudden cardiac death) and cardiomyoplasty (which prevents further dilatation of the heart and provides additional cardiac assistance). We report the clinical course of a patient who had cardiomyoplasty after cardioverter/defibrillator implantation and pacemaker insertion. It is a rare case in which three different devices cardioverter/defibrillator, pacemaker, and cardiomyostimulator) are functioning together without crosstalk.

Statin therapy reduces differentiation of ventricular fibroblast to myofibroblasts in human failing heart

GABA and its synthesising enzyme, glutamate decarboxylase, have been detected in the rat kidney [1–2]. GABA has also been found in human plasma and urine [3–4] and most recently, a renoprotective role for GABA has been suggested [5]. We are systematically investigating functional roles for GABA and glutamate in the mammalian kidney. Contractile pericytes regulate vasa recta diameter in response to a number of endogenous vasoactive agents and in doing so regulate medullary blood flow (MBF) [6]. We have utilised the live kidney slice model [6] to demonstrate GABA-mediated constriction of vasa recta that was significantly greater at pericyte sites than at non-pericyte sites (p< 0.01). Conversely, the GABA substrate glutamate (100 ?M) caused a significantly greater vasodilation of vasa recta at pericyte sites compared to non-pericyte sites (p< 0.05). Data presented here identifies a novel role for GABA and glutamate in pericyte-mediated regulation of vasa recta diameter and thus MBF.Obesity frequently associates with chronic inflammatory diseases, including type 2 diabetes. In this study, a combination of a protein hydrolysate, LCPUFAs and a probiotic strain was investigated on the development of high fat diet -induced diabetic risk factors and complications in LDLr-/-.Leiden mice. Male LDLr-/-.Leiden mice at 12 wks of age received a high fat diet (HFD) for 21 wks with or without a combination of an extensive casein hydrolysate, docosahexaenoic acid (DHA), arachidonic acid (ARA), and Lactobacillus Rhamnosus GG (LGG). Both HFD and intervention diet were isocaloric and casein from HFD was replaced with casein hydrolysate in the test diets. The addition of DHA/ARA in the test diets was controlled for in the HFD. Moreover, a PBS gavage control group was included to control for potential effects of LGG gavage. There were significant beneficial effects of the hydrolysate/ARA/DHA/LGG composition versus the HFD control group including reduced body weight gain, lower plasma levels of insulin, cholesterol and triglycerides, lower systemic inflammation, improved adipose tissue quality and mass, and improved kidney and liver function. In a follow up study, evaluating the individual components of the test formulation, some of the outcomes were attributable to the hydrolysate or LGG. A combination of an extensive casein hydrolysate, ARA, DHA and LGG reduces the detrimental effects of HFD on the development of obesity and its metabolic complications. Main risk factors for the metabolic syndrome such as adipose tissue and chronic inflammation were markedly reduced which could provide a rationale for the beneficial effects observed.OBJECTIVETo evaluate the impact of a mobile phone SMS text message intervention on the exclusiveness of breastfeeding (EBF) in infants 0–6 months. METHODSA two-arm parallel randomized controlled tr...