Raul Garcia-Rinaldi

In Situ Preservation of Cadaver Kidneys for Transplantation: Laboratory Observations and Clinical Application

Many kidneys obtained from cadaver donors undergoing sudden cardiac arrest cannot be transplanted due to the long periods of warm ischemia from the moment of arrest to nephrectomy. A double-balloon-triple-lumen catheter for the rapid in situ preservation of cadaver kidneys has been designed. Used in combination with equipment routinely found in any hospital, it can cool human kidneys in situ to 10–15 C and maintain this temperature until nephrectomy can be performed. Kidneys preserved with this catheter have functioned after transplantation into suitable recipients. This report describes the design and laboratory evaluation of this new device, its clinical effectiveness and technique of insertion.

Surgical management of penetrating injuries of the esophagus

Abstract Although well protected and infrequently injured, penetration of the esophagus has a reported mortality of 10 to 30 per cent. The results of the management of seventy-seven patients with noniatrogenic penetrating injuries of the esophagus were reviewed. The region of esophageal injury was cervical in forty-five patients, intrathoracic in twenty-one patients, and intraabdominal in eleven patients. Gunshot wounds accounted for 75 per cent of the injuries. The overall mortality was 23 per cent. The highest morbidity and mortality was among patients with intrathoracic injuries, due to both difficulty in exposure and complexity of associated injuries. Because of the high incidence of late complications in intrathoracic injuries, cervical diversion and tube gastrostomy or complete esophageal exclusion must be considered early. Fundoplastic procedures were used in four patients with distal esophageal injuries. Although the overall mortality from truncal penetrating wounds has improved in recent years, the mortality from esophageal injuries remains high, reflecting a need for advancement in initial operative management.

Improving the efficiency of wound drainage catheters

We have modified the most commonly utilized wound drainage system to further reduce the incidence of postoperative accumulation of fluid under the skin flaps. This modification allows more efficient removal of debris, loose tissue fragments, and clots from the wound catheters and insures a constant negative pressure in the system. These maneuvers lengthen the usefulness and improve the efficiency of the catheters and have reduced the incidence of fluid accumulation.

Aneurysm of the Main Pulmonary Artery: Long-Term Survival after Aneurysmorrhaphy and Closure of a Ventricular Septal Defect

Pulmonary artery aneurysm (PAA) usually carries an ominous prognosis due to the associated pulmonary hypertension. Six years ago a patient with a PAA secondary to cystic medial necrosis and pulmonary hypertension due to a ventricular septal defect (VSD) was treated by aneurysmorrhaphy and closure of the VSD. Although the patient had early postoperative cardiac failure, his cardiopulmonary status stabilized, and he has done well without recurrence of his aneurysm or cardiac failure. This report summarizes the patients clinical course, operative treatment, and long-term follow-up.

Left ventricular volume reduction and reconstruction in ischemic cardiomyopathy.

AbstractBackground: Ischemic cardiomyopathy can be the result of large or small my‐ocardial infarctions or due to myocardial hibernation. Patients with an end‐systolic volume index >100 mL/m2 do not benefit from revascularization alone and require an operation that reduces ventricular volume. Various approaches to reduce ventricular volume have been described. We applied several of these techniques in patients with end‐stage ischemic cardiomyopathy. Methods: Forty eight patients with end‐stage ischemic cardiomyopathy (Class III‐IV) underwent left ventricular volume reduction operations with coronary revascularization and mitral valve repair or Alfieri valvoplasty. Fourteen patients underwent interpapil‐lary resections, 22 anterior resections, 4 posterior resections, 2 anterior and posterior resections, and 6 patients reduction of left ventricular volume with endocavitary patches. Results: All the techniques used improved left ventricular function. Analysis of mortality revealed that extensive resections (interpapillary, anterior, and posterior resection) had a 43% mortality. However, a limited resection or a ventricular reconstruction with an endocavitary patch had only a 12.5% mortality. When we changed our approach to a more conservative one, mortality was reduced from 26% the first 12 months to 13% in the last 15 months of the study. Conclusions: Ischemic cardiomyopathy has a poor prognosis if the end‐systolic volume index exceeds 100 mL/m2. Various procedures exist to reduce left ventricular volume. Extensive ventricular resections improve ventricular function, but have a high mortality. This led us to use other methods of ventricular volume reduction such as more conservative resections combined with left ventricular reconstructions or ventricular volume reduction with endocavitary patches. Mortality was reduced significantly by this approach. The patients that survived have remained Class I‐II in a follow‐up that extends up to 30 months. Surgical therapy of Class III‐IV ischemic cardiomyopathy is feasible, but aggressive ventricular resections have a high mortality. We advocate a more reconstructive approach with limited or no ventricular resection.

The anatomic basis for the occasional failure of transfemoral balloon catheter thromboembolectomy.

A Fogarty® balloon catheter was advanced from the common femoral artery through the popliteal artery and its branches in 15 cadavers. The catheter passed into the peroneal branch 89% of the time. In all 15 cadavers, the peroneal artery was the direct continuation of the popliteal artery and the arterior tibial and posterior tibial arteries branched off at varying angles from the popliteal. This provides an anatomic explanation for the occasional failure of transfemoral Fogarty® catheter embolectomy of the leg. Our study suggests that if the patients foot does not improve after Fogarty embolectomy, the popliteal artery should be exposed and the catheter directed into the shank arteries using vascular forceps.

Surgical Treatment of Aortic Dissections: Initial Experience With the Adventitial Inversion Technique

BACKGROUND The adventitial inversion technique obliterates the false lumen and converts a dissected aorta into a conduit with tough adventitia on the inside and outside. Dacron grafts can be anastomosed to the aorta with fine sutures, which hold without tears. METHODS From August 1995 to March 1997, we treated 6 patients with acute dissecting aneurysms. Three aneurysms were type I (A) involving the entire aorta, two type II (A) involving the ascending aorta, and one type III (B) involving the thoracoabdominal aorta. Circulatory arrest was used in 3 patients, 1 with type I aneurysm (A), 1 type II (A), and 1 type III (B). RESULTS All Dacron-aorta anastomoses held sutures well and did not bleed intraoperatively or postoperatively. One patient (type II [A]) died of intraoperative low cardiac output. In patients with type I (A) aneurysms, the false lumen was obliterated, but 1 patient required resection of a 6-cm abdominal aortic aneurysm. CONCLUSIONS The adventitial inversion technique is a safe technique for the treatment of acute dissecting aneurysms, which facilitates operation and solves the problem of intraoperative or postoperative bleeding due to tissue friability.

Suspecting thoracic aortic transection.

Deceleration accidents produce a complex of potentially fatal thoracic injuries. Because early detection is the key to successful management of blunt trauma to the great vessels, emergency physicians must be knowledgeable of signs indicative of these complex injuries. Among more than 10,000 patients presenting to the Ben Taub Emergency Center over an 11-year period with thoracic injuries, 100 had clinical or radiographic clues suggestive of blunt trauma decelerative injury to the great vessels. Of these 100 patients, 23 had transection of the descending thoracic aorta and five had avulsion of the innominate artery. One patient had a double transection. Six patients died in the Emergency Center before proximal control could be achieved.

A technique for spot application of fibrin glue during open heart operations

Several techniques have been described for preparing and applying fibrin glue to control surgical bleeding. However, these methods tend to be cumbersome, expensive, or messy. Furthermore, commercial kits have not been approved by the Food and Drug Administration because of the potential risk of hepatitis contamination. Therefore, we have devised a modified, simpler technique that enables the precise, pinpoint application of fibrin glue. The risk of hepatitis transmission is substantially reduced by using cryoprecipitate plasma instead of fibrinogen from pooled donors. This technique is especially well suited for anastomoses of small vessels or for sealing suture holes in nonporous grafts.

Implantation of pericardial substitutes

Pericardial substitutes have been shown to decrease the formation of pericardial adhesions. For a pericardial substitute to be properly implanted, it must lie over the heart smoothly without buckling and prevent the accumulation of blood under its surface. The technique we describe prevents buckling of the pericardial substitute and consequently reduces the formation of pericardial adhesions.