Randall B. Griepp

Progress in treatment of aneurysms of the aortic arch.

A review of past and current operative procedures for treatment of aneurysms of the aortic arch is presented in conjunction with a series of 14 patients in whom the aortic arch and variable portions of the ascending and descending aorta were replaced utilizing a combination of surface cooling and cardiopulmonary bypass to produce profound total body hypothermia. Arch replacement was carried out during a single period of circulatory arrest. Cardiopulmonary bypass was then utilized to warm the patient and resuscitate the heart. The average cerebral ischemia time was 42 minutes at an average core temperature of 14°C. The average myocardial ischemia time was 68 minutes, and the average duration of cardiopulmonary bypass was 122 minutes. There were 4 deaths in this series. Of the 10 patients undergoing elective operation only 1 died. The remaining patients are alive and well 4 months to 6 years following surgery. This experience indicates that by utilizing total body hypothermia and circulatory arrest, aortic arch replacement can be carried out with superior results. This technique is our method of choice and should find increasing application.RésuméLarticle revoit les techniques opératoires passées et actuelles pour les anévrismes de larc aortique. Chez 14 patients, larc aortique et des segments variables de laorte ascendante et descendante ont été remplacés sous circulation extracorporelle et hypothermie de surface combinées, pour obtenir une hypothermie profonde. La prothèse darc aortique est mise en place sous arrêt circulatoire continu. La circulation extracorporelle est ensuite utilisée pour réchauffer le patient et faire repartir le coeur. La durée moyenne dischémie cérébrale a été de 42 minutes à une température centrale moyenne de 14°C. La durée moyenne dischémie myocardique a été de 68 minutes et celle de la circulation extracorporelle de 122 minutes. Il y a eu 4 décès dans ce groupe de patients, dont un seul sur 10 opérations non urgentes. Les 10 autres patients ont survécu et sont en bon état 4 mois à 6 ans après lopération. Cette expérience montre que larc aortique peut être remplacé par prothèse avec dexcellents résultats sous arrêt circulatoire en hypothermie. Cest la technique que nous utilisons de préférence et nous estimons que ses indications doivent être élargies.

Retrograde intubation in patients undergoing open heart surgery

Cardiovascular changes during difficult intubation were studied in 25 patients undergoing open heart surgery. The study was divided into two phases. Phase A from the first laryngoscopy to the fourth unsuccessful one; Phase B from a stabilization period until after retrograde intubation was performed. During phase A, heart rate (HR) increased significantly from 75 ± 6.5 beatslmin before laryngoscopy to 95 ± 8.5 (p < 0.05) after the last laryn-goscopy. Mean arterial pressure (MAP) also increased from 82.5 ± 4.75 mmHgto 105 ± 5.15 (p<0.005) after the last laryngoscopy. Cardiac index (CI) decreased from 2.9 ± 0.3 L·min-1m-2 before to 2.55 ± 0.2 after the last laryngoscopy. Pulmonary capillary wedge pressure (PCWP) increased from 10.5 ± 1 mmHg before to 19.25 ± 1.5 (p< 0.01) after the last laryngoscopy. No statistically significant changes in HR, MAP, CI, and PCWP occurred before and after intubation during Phase B. Three patients had elevated ST segments during Phase A which responded to IV nitroglycerin and propranolol. None was detected during Phase B. There were more lacerated lips and teeth damaged during Phase A. One patient developed a small peritracheal haematoma after the retrograde intubation, for which no treatment was required. This technique is safe and produces minimal cardiovascular changes for difficult intubation in patients undergoing open heart surgery.RésuméLes effets hémodynamiques lors d’une intubation difficile ont été étudiés sur 25 patients subissants une chirurgie à cœur ouvert. Cette étude a été divisé en deux phases. La phase A comprend la période à partir de la première tentative de laryngoscopie jusqu’au quatrième échec de cette dernière; la phase B débute après une période de stabilisation jusqu’à l’accomplissement d’une intubation rétrograde. Pendant la phase A la fréquence cardiaque (HR) augmenta significativement de 75 ± 6.5 batte-mentslmin. avant laryngoscopie à 95 ± 8.5 (p < 0.05) après la dernière laryngoscopie. La pression artérielle moyenne (MAP) augmenta de 82.5 ± 4.75 mmHg à 105 ± 5.15(p < 0.005) après la dernière laryngoscopie. L’index cardiaque (CI) diminua de 2.9 ± OJL·min-1 m-2 avant la laryngoscopie à 2.55 ± 0.15 après la dernière tentative de laryngoscopie. La pression capillaire pulmonaire bloquié (PCWP) augmenta de 10.5 ± L mmHg avant laryngoscopie à 19.15 ± 1.5 (p<0.01) après la dernière laryngoscopie tentative de laryngoscopie. Aucun changement statistiquement significatif n’a été observé dans la fréquence cardiaque, tension artérielle moyenne, index cardiaque et pression capillaire pulmonaire bloquée avant et après intubation durant la phase B. Trois patients ont démontré une élévation du segment ST durant la phase A repondant à l’administration intraveineuse de nitroglycérine et depropranolol. Aucun changement du segment ST n’a été détecté durant la phase B. On observa des lacérations des lèvres et des bris de dents lors de la phase A. Un patient a développé un petit hématome péritrachéal après l’intubation rétrograde pour lequel aucun traitement ne fut requis. Cette technique est sécure et produit des altérations hémodynamiques minimes lors d’une intubation difficile chez les patients subissants une chirurgie à coeur ouvert.

Use of Stapling Instruments in Surgery for Aneurysms of the Aorta

Since their inception, surgical stapling devices have been used almost exclusively in pulmonary and gastrointestinal procedures. We present our experience with surgical staplers in operations for aneurysms of the aorta. Three illustrative case reports are presented that demonstrate the applicability of surgical stapling devices in excluding aortic aneurysms. Seven patients have undergone operation using this technique, all with excellent technical results. We believe that surgical stapling devices represent a safe, easy, and rapid means of excluding aneurysms of the aorta.

Experience with left ventricular apicoaortic conduits for complicated left ventricular outflow obstruction in children and young adults.

Six patients, ranging in age from 8 to 20 years, underwent left ventricular apicoaortic construction for treatment of complicated left ventricular outflow tract obstruction. All patients had severe left ventricular hypertrophy as determined by echocardiography and electrocardiography. The preoperative gradient across the left ventricular outflow tract was 84 +/- 17 mm Hg (mean +/- standard deviation) (range, 65 to 110 mm Hg), and the preoperative left ventricular end-diastolic pressure was 20 +/- 7 mm Hg (range, 12 to 28 mm Hg). Conduits were placed retroperitoneally with the distal anastomosis to the infrarenal aorta; the porcine valve was positioned in the left upper quadrant. Relief of left ventricular hypertension was complete; the minimal gradient measured intraoperatively was 13 +/- 8 mm Hg (range, 0 to 20 mm Hg). With an average follow-up of 18 months (range, 6 to 24 months), all patients have improved and are in Functional Class I. Four patients were catheterized 12 months postoperatively. They all showed excellent relief of left ventricular hypertension; the conduit was effectively decompressing the left ventricle. This experience suggests that this approach is effective in relieving complex left ventricular outflow tract obstruction with good early results, and that it deserves more frequent application in children.

Cricothyroidotomy for prolonged ventilatory support after cardiac operations

Forty-nine patients required prolonged ventilatory support after cardiac operations. Cricothyroidotomy was used routinely in these patients after approximately 7 days of endotracheal intubation. There were no infections of the median sternotomy wounds despite frequent colonization of the stoma. The only immediate complication was mild stomal bleeding in a patient taking anticoagulants. Nineteen patients (39%) died of underlying disease. The average duration of cricothyroidotomy was 59 days (range, 3 to 270 days). Cannulas were successfully removed in all survivors after an average of 38 days (range, 6 to 187 days). All of the patients were followed by personal interview, telephone contact, or contact with the referring physician. The average length of follow-up was 17 months (range, 2 to 50 months). All symptomatic patients were evaluated by laryngoscopy and bronchoscopy. One patient required endoscopic removal of granulation tissue from the stomal site; 2 others required tracheal resection for stenosis at the balloon site. There were no instances of subglottic stenosis. There were 4 late deaths, none of which was related to the cricothyroidotomy. Based on these findings, we suggest that cricothyroidotomy, with its low complication rate, is the procedure of choice for patients requiring prolonged mechanical ventilation after cardiac operations.

Anaesthesia for aortic arch aneurysm repair: Experience with 17 patients

Mortality and morbidity during aortic arch aneurysm repair is high despite improvements in surgical technique which attempt to assure brain protection during surgery. We successfully managed 17 patients using deep hypothermia and circulatory arrest. Anaesthesia consisted of pancuronium, fentanyl, plus isoflurane or halothane if needed. Pulmonary artery and arterial catheters were inserted. Surface cooling was performed followed by core cooling on cardiopulmonary bypass, using a heat exchanger. Total circulatory arrest was performed when esophageal temperature reached 12-14 ° C after previous administration of thiopenlone 30 mg*kg-1, methylprednisolone 2 gm, furosemide 40 mg and mannitol 25 gm. At that time the head was packed in ice and surgical correction performed. Mean arrest time was 36.5 ± 13 minutes al a mean oesophageal temperature of 12.5 ± 0.75° C. No serious, permanent neurological deficit was found. Tracheostomy was required in five patients of whom two had chronic obstructive pulmonary disease (COPD). Two of these patients died of adult respiratory distress syndrome (ARDS) and renal failure. The reported technique is safe and can be easily used in patients undergoing aortic arch aneurysm repair.RésuméLe taux de mortalité et de morbidité durant la correction chirurgicale de t’aneurysme de l’arche de l’aorte est encore élevé malgré l’amélioration de la technique chirurgicale visant à assurer la protection du cerveau. Nous avons utilisé avec beaucoup de succès un système combinant l’hypothermie profonde et l’arrêt complet de la circulation. L’anesthésie administrée consistait en du pavulon, dufentanyl, de l’isoflurane ou de l’halothane si nécessaire. Le refroidissement de surface a précédé le refroidissement central pratiqué avec la machine cαurpoumon. L’arrêt complet de la circulation s’est produit quand la température de l’αsophage était de 12-14° C après l’administration de thiopentone de sodium (30 mgs.kg-1), de méthylprednisolone 2 g, de furosemide 40 mgs et de mannitol 25 gs. A ce moment la tête a été complètement recouverte de sacs de glace et la correction chirurgicale pratiquée. Le temps moyen d’arrêt circulatoire était de 36.5 ± 13 minutes et la température de l’αsophage 12.5 ± 0.75° C. Nous ne rapportons aucune fatalité durant l’intervention chirurgicale. Nous n’avons constaté aucun déficit neurologique permanent chez nos patients.La trachéotomie a été pratiquée chez cinq patients souffrant d’insuffisance respiratoire. Deux décès ont été rapportés des suites d’insuffisance rénale et respiratoire.Cette technique est sûre et pratique et diminue la chance de complications durant la résection de l’aneurysme de l’arche de l’aorte.

Unusual manifestations of aortic dissection

Two unusual manifestations of aortic dissection, rupture into the main pulmonary artery and rupture into the inferior vena cava, are presented. The latter complication has not been reported previously in the literature. The value of inferior vena caval oximetry to delineate the site of fistulous communication is stressed.

Anomalous origin of the right coronary artery from the pulmonary artery

Anomalous origin of the right coronary artery from the pulmonary artery was diagnosed by selective left coronary artery angiography in an asymptomatic five-year-old boy with a continuous murmur. The anomalous coronary artery, along with a cuff of the pulmonary artery, was re-implanted into the aorta. The patient is asymptomatic five years postoperatively.

Successful Treatment of Multiple Simultaneous Great Vessel Disruptions

Survival following ruptures of the thoracic aorta at sites other than the aortic isthmus is exceedingly rare. Herein we describe a successful outcome in a 62-year-old woman with ascending and isthmic aortic lacerations compounded by disruptions of the subclavian-innominate artery junction and the left vertebral-subclavian junction. Chest wall instability and a myocardial contusion further complicated her case.