Roger R. Ecker

Intraaortic balloon counterpulsation in patients in cardiogenic shock, medically refractory left ventricular failure and/or recurrent ventricular tachycardia

Of the 27 patients described, 23 were in cardiogenic shock, 2 had severe left ventricular failure, and 2 had medically refractory ventricular tachycardia. Utilizing intraaortic counterpulsation, adequate systemic blood pressure was initially restored in 19 patients. Nine of these were subsequently weaned from circulatory assistance, but only three were discharged from the hospital and are currently alive. The remaining 10 patients who derived initial benefit from circulatory assistance were balloon-dependent in that they could not be weaned from circulatory assistance. Eight of these patients subsequently underwent cardiac catheterization; four had inoperable disease. The remaining four patients underwent surgery for either resection of the area of infarction and/or for myocardial revascularization; only one survived to subsequently leave the hospital. Ventricular volumes were abnormal and ejection fractions were below 30 per cent in all the patients in cardiogenic shock except one who underwent cardiac catheterization and ultimately died. Ejection fractions were greater than 30 per cent in the two patients with cardiogenic shock who were weaned from balloon support and survived to leave the hospital without surgery. Both of these patients had inferior myocardial infarction. The data obtained from this experience suggest that intraaortic counterpulsation is a very useful adjunct to currently existing medical measures to treat both cardiogenic shock and medically refractory left ventricular failure but that most patients have such extensive disease that they can neither be weaned from balloon support nor undergo successful infarctectomy or myocardial revascularization.

Injuries of the trachea and bronchi

Abstract There were 105 injuries of the trachea and bronchi in Dallas County over the ten-year period 1958 through 1967. Twenty-four patients were alive (AOA) and 81 were dead (DOA) on admission. Survival to reach the hospital was related to age, wounding agent, site and severity of injury, and major associated injuries, particularly cardiovascular. Diagnosis in AOA patients could be suspected on the basis of symptoms and was confirmed by bronchoscopy. Definitive treatment included primary suture in 17 patients and tracheostomy alone in 4. Of the 21 patients with injuries to the trachea, 18 did well. Poor results were related to associated injuries or inadequate treatment. The 3 patients with bronchial injuries were treated by primary suture. One patient died of late stricture. Although most tracheal and bronchial injuries are associated with other fatal injuries, the prognosis in those patients who arrive alive is good. Immediate primary closure of the wound offers the best chance for a good result.

Control of Intractable Ventricular Tachycardia by Coronary Revascularization

Ventricular tachycardia (VT) is an arrhythmia that has an ischemic origin in up to 74% of cases and results in a 42 to 67% mortality when it is recurrent and paroxysmal. Present therapy is aimed at suppression of the abnormal rhythm but does not alter the prognosis of the underlying ischemic heart disease. A new concept of treatment of VT is introduced that is based on direct coronary revascularization by the aorta to coronary, saphenous vein-bypass technique. The method was successfully applied in a 61-year-old man who developed episodes of VT 2 months after myocardial infarction. Maximal medical therapy in a coronary care unit for 26 days did not abolish the arrhythmia which occurred as frequently as seven times an hour. Coronary angiography and aortocoronary bypass grafting were done when the patient developed electrocardiographic and enzyme evidence of subendocardial myocardial infarction and symptoms of cerebral ischemia. The patient remains free of arrhythmia 1 year later, and his exercise capability is now normal for his age. Follow-up coronary angiography is presented. Coronary revascularization has been shown to abolish angina pectoris. This report demonstrates that aortocoronary bypass grafting can abolish an arrhythmia of ischemic origin. When persistent or recurrent VT fails to respond to all medical therapy, direct coronary revascularization should be considered to control this ischemic arrhythmia.

A Comparative Study of IPPB, the Incentive Spirometer, and Blow Bottles: The Prevention of Atelectasis Following Cardiac Surgery

Following cardiac operations, 145 patients were treated with either intermittent positive-pressure breathing (IPPB), blod bottles, or an incentive spirometer in an attempt to alter the incidence of atelectasis. Pulmonary complications occurred in 30% of the patients receiving IPPB, 15% of those using an incentive spirometer, and 8% of those using blow bottles. Gastrointestinal side-effects occurred in 20% of the IPPB group and were rare in other groups. The cost of IPPB is also considerably greater than either incentive spirometry or blow bottles. IPPB is not essential to prevention of atelectasis in postoperative cardiac surgical patients and may be inferior to other methods.

Vascular complications of intraaortic balloon counterpulsation

Between February 1973 and December 1986, 4,787 patients underwent open heart surgery at Samuel Merritt Hospital. Retrospective analysis revealed 395 (8 percent) consecutive patients who required hemodynamic support with the intraaortic balloon pump. Thirty percent of the patients had preoperative placement, 56 percent needed the balloon in order to wean from cardiopulmonary bypass, and 14 percent required placement in the postoperative period. The intraaortic balloon pump was instituted with multiple techniques and insertion sites. Three hundred eighty-three balloon catheters (96 percent) were inserted through the groin by surgical cutdown or a percutaneous approach. The remaining devices were inserted through the aortic arch. A 12 F. catheter was utilized in 239 patients (61 percent) and a smaller 10.5 F. catheter was placed in 156 patients (39 percent). The hospital mortality rate was 47 percent. Seventy-two of the 395 patients (24 percent) sustained vascular complications related to balloon use. Major complications occurred in 43 patients. Twenty-nine patients sustained minor complications that resolved spontaneously with balloon removal. Risk factors evaluated included patient gender, New York Heart Association class, catheter size, method of introduction, duration of counterpulsation, and presence of symptomatic peripheral vascular disease. Since percutaneous placement was associated with a significant decrease in complications, we concluded that use of the smaller 10.5 F. catheter placed percutaneously is the safest means of employing the intraaortic balloon pump. A monitoring line is placed percutaneously through the femoral artery in high-risk patients before operation. This allows easier access for intraaortic balloon pump placement in hypotensive patients. The presence of a clinical history of peripheral vascular disease was also a highly significant risk factor for vascular complications. Other risk factors increasing the likelihood of vascular compromise included catheter size and duration of counterpulsation.

Closure of bronchopleural fistulas by an omental pedicle flap

Bronchopleural cutaneous fistulas are a serious problem that are difficult to treat with any assurance of success. Thoracoplasty, muscle pedicle grafts, and attempts at reclosure have been used with limited success. We have used the omental flap technique in the management of five patients with bronchopleural cutaneous fistulas. In our patients and in four cases in the literature, the success rate has been 100 percent. The omental pedicle flap is a simple way to close bronchopleural fistulas. It avoids extensive chest wall dissection and destruction in patients who often have marked respiratory embarrassment and other underlying disease. The results have been excellent.

Autologous blood retrieval in thoracic, cardiovascular, and orthopedic surgery

A significant amount of red blood cells were conserved with use of the Cell Saver in cardiac surgery patients and in some orthopedic and vascular surgery patients. No major complications have been associated with its use in our cases. Our results are similar to those of others who have reported on the use of this device. In the cardiac surgery patients we observed significant serum protein losses which had to be replaced. We recommend the use of intraoperative albumin to help maintain adequate urinary output and hemodynamic stability.

Early detection and management of left ventricular free wall rupture during acute myocardial infarction

Abstract Left ventricular free wall rupture is generally perceived to be universally fatal. 1–3 Although most patients who have rupture with acute pericardial tamponade die rapidly, the process may be slow enough to permit diagnosis and successful management. 4–6 We present our experience with 2 patients in whom surgical management of ventricular free wall rupture was accomplished successfully.

Traumatic Esophageal Perforation

Abstract Thirty-two consecutive unselected patients with traumatic esophageal perforation treated in the past seven years were reviewed. Perforation was due to gunshot wounds, stab wounds, instrumentation, or massive lye ingestion. Of the 12 patients seen in the first four years (Group I) who were treated with primary closure or tube thoracostomy, intravenous fluids, and antibiotics, 5 died. In a second group of 15 patients seen in the last three years (Group II) who received 2,000 to 3,000 calories daily either intravenously or by tube feeding, only 1 patient died; 5 other patients with high, isolated injuries of the cervical esophagus who went home within one week were excluded from Group II. The time from perforation to definitive therapy was approximately the same in both groups, as was the severity and type of perforation. Complications were similar in each group and included abscess, empyema, mediastinitis, hemorrhage, fistula, and pneumonia. Three times the associated injuries per person occurred in Group II as in Group I. Therefore there appeared to be a greater potential for complications and death, but only 1 of the 15 patients died as compared with 5 of the 12 Group I patients. This limited mortality appeared to be due to the increased nutritional regimen.

Long-Term Membrane Oxygenation in Respiratory Failure

Abstract Three patients with acute terminal respiratory failure who did not respond to maximum constant controlled-volume ventilation at 100 cm. H 2 O inhalation pressure with constant positive-pressure breathing of 20 cm. H 2 O were treated by membrane oxygenation for a total of 12 days. There was marked clearing of the lungs on roentgenogram. Compliance increased, and shunting decreased. All patients were able to maintain an adequate arterial Po 2 off membrane oxygenation and on intermittent positive-pressure breathing before their deaths. Deaths were due to anoxia, renal failure, and a cerebrovascular accident (CVA). Each patient was potentially a survivor; however, the CVA and renal failure were the results of pumping and heparinization. The best route for cannulation is still unknown, so both venovenous and venoarterial cannulations were done in these patients.