Thomas J. Takach

Sinus of Valsalva aneurysm or fistula: management and outcome.

BACKGROUND Few large or long-term series exist regarding the management of patients with sinus of Valsalva aneurysms or fistulas (SVAFs). METHODS Between 1956 and 1997, 129 patients presented with a ruptured (64 cases; 49.6%) or nonruptured (65 cases; 50.4%) SVAF. The patients included 88 men and 41 women, with a mean age of 39.1 years. Associated findings included a history of endocarditis (42 cases; 32.6%), a bicuspid aortic valve (21 cases; 16.3%), a ventricular septal defect (15 cases; 11.6%), and Marfans syndrome (12 cases; 9.3%). Operative procedures included simple plication (61 cases; 47.3%), patch repair (52 cases; 40.3%), aortic root replacement (16 cases; 12.4%), and aortic valve replacement/repair (75 cases; 58.1%). RESULTS There were five in-hospital deaths (3.9%): four due to preexisting sepsis and endocarditis and one that followed dehiscence of the repair in a patient with Marfans syndrome. Two patients (1.6%) had strokes during the early postoperative period. The survivors were followed up for 661.1 patient-years (5.3 years/patient). The following late complications occurred: prosthetic valve malfunction (5 cases; 3.9%), prosthetic valve endocarditis (3 cases; 2.3%), SVAF recurrence (2 cases; 1.6%), thrombosis (1 case; 0.8%), and anticoagulation-related bleeding (1 case; 0.8%). CONCLUSIONS Resection and repair of SVAF entails an acceptably low operative risk and yields long-term freedom from symptoms. Early, aggressive treatment is recommended to prevent endocarditis or lesional enlargement, which causes worse symptoms and necessitates more extensive repair.

Is an Integrated Approach Warranted for Concomitant Carotid and Coronary Artery Disease

BACKGROUND The management of patients with severe, concomitant coronary and carotid artery occlusive disease is controversial. METHODS Between 1975 and 1996, 512 patients (mean age, 64.9 years; 70% male) were admitted for coronary revascularization; 316 (61.7%) had asymptomatic, severe carotid disease (stenosis > 70%) and 196 (38.3%) had symptomatic carotid disease (159 [31.1%] with transient ischemia and 37 [7.2%] with completed stroke). In group 1, coronary revascularization and carotid endarterectomy were simultaneously performed in 255 patients (49.8%) with unstable angina. In group 2 (staged approach), carotid endarterectomy was performed before coronary revascularization in 257 patients (50.2%) without unstable angina. RESULTS Before 1986, the incidence of stroke and death was greater in group 1 (n = 149) than in group 2 (n = 156) (14 [9.4%] versus 4 [2.6%]; p < 0.01). Since 1986, outcomes in group 1 (n = 106) and group 2 (n = 101) have been similar for stroke (2 [1.9%] versus 2 [2.0%]), death (4 [3.8%] versus 3 [3.0%]), and myocardial infarction (4 [3.8%] versus 5 [5.0%]). Significant univariate and multivariate predictors of adverse outcome were primarily heart-related (reoperation, intraaortic balloon use, ejection fraction < 0.50, and angina grade 4 for death; age > 70 years and congestive heart failure for stroke). CONCLUSIONS Despite highly selected populations, contemporary surgical results do not indicate that staged treatment of severe, concomitant coronary and carotid artery occlusive disease has an advantage over simultaneous treatment. Advances in myocardial protection and perioperative hemodynamic management may account for the low incidences of stroke and death in these operations.

Primary cardiac tumors in infants and children: Immediate and long-term operative results

BACKGROUND The literature contains few large or long-term series involving infants and children with primary cardiac tumors. This article summarizes our 35-year experience with such lesions. METHODS Between January 1961 and January 1996, 40 infants and children (mean age, 3.3 years; range, 2 days to 17 years; 65% female) were diagnosed at our institution with primary cardiac tumors. Of these tumors, 37 (92%) were benign and 3 (8%) were malignant. Tumors were resected in 38 patients (95%). In 2 patients (5%), biopsy confirmed rhabdomyoma; however, presenting symptoms spontaneously resolved, so these patients did not undergo tumor resection. Follow-up echocardiographic studies showed a diminishing tumor mass in each of these patients. RESULTS Immediate, symptom-free status was achieved in all patients. There were two early deaths, for an operative mortality of 5%. Three late postoperative deaths (7.5%) occurred as follows: 1 patient with a myocardial hamartoma died at 3 months of congestive heart failure. Another patient with a recurrent rhabdomyosarcoma died at 6 months, and a third patient with a recurrent fibrosarcoma died at 28 months. Long-term follow-up was available for 34 survivors (97% complete) and totaled 240.2 patient-years (mean, 7.1 years/patient). All remaining survivors were without evidence of presenting symptoms and tumor recurrence or progression. CONCLUSIONS The data suggest that an aggressive operative approach is warranted for benign symptomatic and malignant tumors. This aggressive approach has resulted in extended symptom-free status in patients with benign lesions, and significant palliation and longer survival in patients with malignant lesions, with acceptably low operative risk.

Concomitant subclavian and coronary artery disease

BACKGROUND Proximal subclavian artery occlusive disease in the presence of a patent internal mammary artery used as a conduit for a coronary artery bypass graft procedure may cause reversal of internal mammary artery flow (coronary-subclavian steal) and produce myocardial ischemia. METHODS We reviewed outcome to determine whether subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal. Between 1985 and 1997, 20 patients had either concomitant subclavian and coronary artery disease diagnosed before operation (group 1, 5 patients) or symptomatic coronary-subclavian steal occurring after a previous coronary artery bypass graft procedure (group 2, 15 patients). Patients in group 1 received direct subclavian artery bypass and a simultaneous coronary artery bypass graft procedure in which the ipsilateral internal mammary artery was used for at least one of the bypass conduits. Patients in group 2 received either extrathoracic subclavian-carotid bypass (5 patients, 33.3%) or percutaneous transluminal angioplasty and stenting (10 patients, 66.7%) as treatment for symptomatic coronary-subclavian steal. RESULTS All patients were symptom-free after intervention. One patient treated with percutaneous transluminal angioplasty and stenting died of progressive renal failure. Follow-up totaled 58.5 patient-years (mean, 3.1 years/patient). In group 1, primary patency was 100% (mean follow-up, 3.7 years). In group 2, one late recurrence was treated by operative revision, yielding a secondary patency rate of 100% (mean follow-up, 2.9 years). CONCLUSIONS Subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal with acceptably low operative risk. Midterm follow-up demonstrates good patency.

Spontaneous splanchnic dissection: Application and timing of therapeutic options

BACKGROUND Spontaneous splanchnic dissection (SSD) occurs infrequently and has a poorly defined natural history. Few studies address the application, timing, and consequences of therapeutic options. Our goal was to apply conservative (non-operative) management in the care of each patient, reserving interventions for specific indications that may be predictive of adverse outcomes. METHODS Between 2003 and 2008, 10 consecutive patients (mean age 54.7-years-old, 70.0% male) presented with 11 SSDs involving either the celiac artery (n = 6), superior mesenteric artery (n = 3), or both (n = 1). Each patient had acute, spontaneous onset of persistent abdominal pain and was diagnosed with SSD following multidetector row computed tomographic angiography (CTA). Non-operative management (anticoagulation, anti-impulse therapy, analgesics, and serial CTA examinations) was initially used in 9 patients. Endovascular (n = 2) or operative (n = 2) intervention was performed either immediately (n = 1) or following failed medical management (n = 3) in 4 patients for specific indications that included persistent symptoms (n = 3), expansion of false lumen (n = 3), and/or radiologic malperfusion (n = 3). RESULTS All patients were asymptomatic after successful non-operative management or following intervention. No morbidity occurred. Upon complete follow-up (mean 13.4 months, range, 2 to 36 months), all patients remained asymptomatic. Preservation of distal perfusion with either thrombosis or ongoing regression of false lumen was achieved in 5 patients who received only non-operative management and in 4 patients following intervention. A stable chronic dissection was present in 1 patient who had only non-operative management. CONCLUSION Successful outcomes following SSD may be achieved with either non-operative therapy alone or intervention if persistent symptoms, expansion of false lumen, and/or malperfusion occur. The unpredictable response of the false lumen to conservative management mandates close, long-term follow-up. Endovascular and operative interventions produced similar outcomes in a small number of patients with limited follow-up. Although SSD is currently perceived as rare, the increasing use of CTA may prove that the true incidence has been underestimated.

Continuous Measurement of Intramyocardial pH: Correlation to Functional Recovery Following Normothermic and Hypothermic Global Ischemia

The continuous measurement of intramyocardial pH was used to follow the progression of ischemia and was correlated to the recovery of left ventricular function following normothermic (38 degrees C) and hypothermic (25 degrees C) global ischemia. New miniature myocardial transducers, which incorporate fiberoptic technology and dual pH- and temperature-sensing capability, were placed into the left ventricular free wall and septum of 52 sheep undergoing cardiopulmonary bypass. Left ventricular stroke work as a function of mean left atrial pressure curves were generated before and after cardiopulmonary bypass by volume loading with whole blood. Functional recovery was determined by the ratio of the integrals of the preischemic and postischemic function curves. Control sheep (N = 11) did not undergo ischemia. Three groups (N = 41) underwent aortic cross-clamping until pH reached 7.0, 6.8, or 6.6. The preischemic myocardial pH averaged 7.42 +/- 0.01. Following both normothermic and hypothermic global ischemia, no significant difference was demonstrated in recovery of function between control (pH 7.4) and pH 7.0 groups at either temperature. However, recovery of function of the pH 6.8 and pH 6.6 groups was significantly decreased (p less than 0.01) versus control and pH 7.0 groups at both temperatures. No significant difference in recovery of function was demonstrated at any pH level when normothermic versus hypothermic groups were compared. However, hypothermia provided increased time (p less than 0.001) before each level of function was reached with a slower rate of change of pH (p less than 0.01) compared with the corresponding same pH group in sheep undergoing normothermic (38 degrees C) cardiopulmonary bypass.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous Measurement of Intramyocardial pH: Relative Importance of Hypothermia and Cardioplegic Perfusion Pressure and Temperature

The continuous measurement of intramyocardial pH was used to follow the progression of ischemia and permit correlation to functional recovery. Adequacy of myocardial preservation following 38 degrees C or 25 degrees C global ischemia alone or with the administration of one or two doses of 38 degrees C, 25 degrees C, or 1 degree C crystalloid cardioplegia at aortic root perfusion pressures of 90 mm Hg or 130 mm Hg was assessed. A new miniature myocardial transducer incorporating fiberoptic technology and dual pH and temperature-sensing capability was placed into the left ventricular free wall and septum of 44 sheep undergoing ischemic arrest during cardiopulmonary bypass. All groups underwent global ischemia until myocardial pH was 6.8. An intramyocardial pH level of 6.8 reliably correlated to similar levels of functional recovery in each group. Aortic root perfusion pressure of 130 mm Hg provided enhanced myocardial protection by increasing the total ischemic time (5 to 10 minutes) with one (p less than 0.01) or two (p less than 0.001) doses of cardioplegic solution until a given functional level of recovery was attained. Aortic root perfusion pressure of 90 mm Hg provided no added benefit in total ischemic time, rate of change of pH, or degree of recovery of function. Hypothermic (25 degrees C) global ischemia alone enhanced myocardial protection by providing increased time (p less than 0.01) until a given functional level of recovery was attained with a slower rate of change of pH (p less than 0.01) compared with normothermic (38 degrees C) global ischemia alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Rejection after Cardiac Transplantation: Detection by Interstitial Myocardial pH

Intramyocardial pH was assessed as a potential marker for clinical evaluation and treatment of acute rejection following cardiac transplantation. Fifteen cats underwent forty operative procedures. Following intra-abdominal heterotopic heart transplantation, serial laparotomies were performed in the early (days 0 to 2), intermediate (days 5 to 7), and late (days 7 to 16) postoperative periods. Rejection was assessed by serial clinical examinations, ECG analyses, B-mode echocardiography, histological and ultrastructural analyses, and measurements of interstitial myocardial pH. Intramyocardial pH was measured by a new miniature (0.6 X 3.0 mm) fiberoptic pH transducer. At confirmed rejection, concomitant laparotomy and thoracotomy were performed and pH sensors were implanted in both native (anatomical) and graft hearts. Nine animals at rejection were given methylprednisolone and changes in graft and native heart pH were measured. The pH during absence of rejection, mild acute rejection, and severe acute rejection averaged 7.430 +/- 0.019, 7.233 +/- 0.040 (p less than .02), and 6.860 +/- 0.066 (p less than .02), respectively (mean +/- standard error of the mean). A progressive decline in pH was noted in each heart. In animals receiving steroids, graft heart pH increased over 90 minutes from 6.852 +/- 0.065 to 7.043 +/- 0.077 (p less than .05). Although pH decline may be secondary to either inflammatory or ischemic etiology, histological and ultrastructural analyses demonstrate a predominant inflammatory response with progressive mononuclear cell infiltration, interstitial edema, vascular wall edema, infiltration by polymorphonuclear neutrophil leukocytes, vacuolation of sarcoplasmic reticulum, and disarray of myocytes associated with falling pH. Degree of pH change correlated closely with degree of histological rejection, presence of ECG voltage decline, and change in wall thickness by ultrasound.

Preocclusive Carotid Artery Thrombosis: Pathogenesis and Management

In this report, the authors review the presentations, angiographic findings, and outcomes of eight cases involving patients who had atherosclerotic compromise of the proximal internal carotid artery and were developing distal thrombosis. They discuss the pathogenesis and implications of such lesions and review the management strategy used at this institution. Between 1994 and 1995, 606 consecutive patients underwent carotid endarterectomy (CEA) at this institution. Among this group, four consecutive patients (0.66%, 4/606) were identified by angiography to have preocclusive carotid artery thrombosis. An additional four patients with the same radiologic finding who had presented between 1980 and 1993 were also identified and included in this series. All eight patients were treated with anticoagulation and emergent CEA and thrombectomy. Complete resolution of presenting symptoms and freedom from perioperative stroke and death were achieved in seven patients (88%, 7/8). In one patient (12%, 1/8) the perioperative course was complicated by development of a carotid artery-cavernous sinus fistula and stroke. The catastrophic potential of preocclusive carotid artery thrombosis mandates immediate intervention. Anticoagulation, CEA, and thrombectomy can result in freedom from the adverse outcomes of stroke and death. However, special care must accompany thrombectomy in order to avoid complications and their associated morbidity.