Victor A. Jebara

Revival of the radial artery for coronary artery bypass grafting

Eighteen years after its first introduction for coronary artery revascularization, the radial artery (RA) was reinvestigated because of unexpected good long-term results in the early series. Since July 1989, 104 patients underwent myocardial revascularization using 122 RA grafts (18 patients received two grafts). The left internal mammary artery (IMA) was concomitantly used as a pedicled graft in 100 cases and the right IMA in 19 cases; a free IMA graft was used in 29 cases and a saphenous vein graft in 24 cases. A mean of 2.8 grafts per patient were performed. Nine patients underwent associated procedures: carotid endarterectomy (3), aortic valve replacement (3), Bigelow procedure (1), and mitral valve repair (2). The target artery receiving the RA was the circumflex (n = 59), diagonal (n = 29), right coronary (n = 27), and left anterior descending (n = 7). One patient died (0.96%) and 2 had perioperative myocardial infarct. Sternal wound infection was noted in 3 cases of double IMA implantation. No ischemia of the hand was observed. All patients received diltiazem started intraoperatively and continued after discharge. In addition aspirin (100 mg/day) was given at discharge. Early angiographic controls (less than 2 weeks) were obtained in the first 50 consecutive patients and revealed 56 of 56 patent RA grafts, 48 of 48 patent left IMA grafts, 11 of 11 patent right IMA grafts, 14 of 18 patent free IMA grafts, and 8 of 9 patent vein grafts.(ABSTRACT TRUNCATED AT 250 WORDS)

The radial artery for coronary artery bypass grafting: Clinical and angiographic results at five years☆☆☆★

OBJECTIVE The aim of this study was to assess the long-term results of use of the radial artery as a conduit for coronary artery bypass grafting. METHODS After revival of the technique in 1989, the radial artery was used as a conduit in 910 patients undergoing coronary artery bypass grafting. A complete follow-up was obtained for the first 102 consecutive patients from 4 to 7 years after the operation (mean 5.27 +/- 1.30 years). Fifty-nine percent of the patients were receiving calcium-channel inhibitors. An electrocardiographic stress test was obtained for 51 patients, with no contraindications found. Routine follow-up angiography was performed in 50 cases, including those of all patients with symptoms. Thus 64 radial artery and 48 left internal thoracic artery grafts were followed up from 4 to 7 years after the operation (mean 5.6 +/- 1.40 years). RESULTS The actuarial survival was 91.6% at 5 years, and the actuarial rate of freedom from angina was 88.7% at 5 years. Four patients underwent percutaneous transluminal angioplasty during the period of follow-up, and there were no reoperations for revision of the bypass. The electrocardiographic stress test showed negative results in 73% of cases, electrocardiographic changes alone in 21%, and clinically positive results in 6%. Angiography showed that the patency rate of the radial artery grafts was 83%. The patency rate of the left internal thoracic artery grafts (n = 47) was 91%. The difference in patency could be related to the implantation sites of the grafts, mainly the circumflex artery (51%) for the radial artery grafts and almost exclusively the left anterior descending artery (94%) for the left internal thoracic artery. CONCLUSION The use of the radial artery for coronary bypass grafting provides excellent clinical and angiographic results at 5 years. Routine use of the radial artery in combination with the left internal thoracic artery can be recommended.

Valve repair in acute endocarditis

Forty patients were operated on in the early phase of active endocarditis between 1980 and 1988. Indications for operation were heart failure (30 patients), severe valvular regurgitation (4), uncontrolled sepsis (2), septic emboli (3), and other (1 patient). Time between onset of endocarditis symptoms and operation ranged from 12 to 45 days (mean, 30 days). The aortic valve was involved in 3 patients; the mitral valve, in 28; both valves, in 7; and the tricuspid valve, in 2. There was no previous underlying valve pathology in 40%. Lesions found were cusp perforation (17 patients), annular abscess (4), vegetation (13), and chordal rupture (22). Positive blood cultures were found in 30 patients (75%). Bacterial findings were Streptococcus in 12 patients (30%), Staphylococcus in 15 (37.5%), gram-negative in 3 (7.5%), and unknown in 10 (25%). Criteria to perform valve repair were adequate antibiotic therapy for at least 1 week and large excision of all macroscopically involved tissues. In all cases, Carpentiers reconstructive techniques were used. Perioperative mortality was 2.5% (1 patient). Reoperation was necessary in 1 patient. Late mortality was 2.5% (1 patient). Repair was assessed either by angiography or by Doppler echocardiography before hospital discharge: 32 patients showed no regurgitation, whereas 7 had mild regurgitation (3 aortic, 4 mitral). Mean follow-up of 30 months was achieved in all survivors. There was no recurrence of endocarditis and no reoperation for valvular insufficiency. We conclude that valve repair in acute endocarditis is possible and effective in most instances.

Total orthotopic heart transplantation: An alternative to the standard technique

An alternative technique of total orthotopic heart transplantation is described. Complete excision of the recipients atria is undertaken. Ventricular as well as atrial orthotopic transplantation is performed.

Dynamic aortomyoplasty to assist left ventricular failure

The efficacy of skeletal muscle contractile force to augment left ventricular function has been demonstrated experimentally and clinically by the cardiomyoplasty procedure. Another approach in biomechanical cardiac assistance is the use of electrostimulated skeletal muscle in an extracardiac position. We describe an autologous counterpulsating device using the native ascending aorta as a ventricular chamber wrapped by an electrostimulated latissimus dorsi muscle flap (LDMF). This model avoids thrombotic complications observed in skeletal muscle neo-ventricles associated with prosthetic chambers. In 8 goats, a right LDMF was transferred to the thoracic cavity by removal of the second rib. In 4 goats, the diameter of the aorta was enlarged by surgical implantation (using lateral clamping) of an autologous pericardial patch. The LDMF was wrapped around the ascending aorta and electrostimulated using an external diastolic pulse generator connected to a sensing myocardial lead and to LDMF pacing electrodes. Hemodynamic studies were performed (left ventricular, aortic, and pulmonary artery pressures and rate of rise of left ventricular pressure). The LDMF diastolic counterpulsation was performed using a burst of 30 Hz, with a delay from the R wave adjusted to provide optimal diastolic augmentation. Percent increase in the subendocardial viability index was calculated during unassisted and assisted cardiac cycles (1:2) at baseline and after acute heart failure induced by the administration of high doses of propranolol hydrochloride (3 mg/kg intravenously). Diastolic aortic counterpulsation by the stimulated LDMF resulted in a significant improvement in the subendocardial viability index both at baseline and after induced cardiac failure in both groups, though the increase was greater in the group with aortic enlargement.

Renal artery pseudoaneurysm after blunt abdominal trauma

Renal artery pseudoaneurysms are rare after blunt abdominal trauma; only 11 cases have been previously reported. Pseudoaneurysms are caused by decelerating injuries of the renal artery after major falls or automobile accidents. Patients may be asymptomatic for many years, and the pseudoaneurysm may expand and rupture before diagnosis or treatment. The patients in four untreated cases died. The diagnosis of renal artery pseudoaneurysm can be made by Doppler sonography, computerized tomography, renal perfusion imaging, or contrast angiography. Treatment requires either surgical or percutaneous intervention. Renal salvage was possible in five of the seven patients treated. We report two additional patients with successful outcomes after surgical intervention.

Causalgia: a wartime experience--report of twenty treated cases.

During the 10-year period from 1975 to 1985 20 patients suffering from causalgia were treated. There were 15 men and five women. Ages ranged from 17 to 45 years (mean, 23). All were war casualties injured by high-velocity missiles. The median nerve was involved in eight cases, ulnar nerve in six, brachial plexus in four, sciatic nerve in four, radial nerve in three, and there were multiple nerve injuries in five cases. The diagnosis of causalgia was based on the characteristic clinical picture and was confirmed by sympathetic blocks. All patients were treated by sympathectomy and all had complete dramatic relief in the immediate postoperative period. Followup ranged from 4 months to 10 years (mean, 5.3 yr).

Isolated extracardiac unruptured sinus of valsalva aneurysms

Reports concerning unruptured, isolated aneurysms of one sinus of Valsalva are rare. These aneurysms usually protrude inside the heart and are very rarely extracardiac. We report 4 cases of isolated, unruptured extracardiac aneurysms of the noncoronary sinus of Valsalva. Clinical symptoms were nonspecific. Operation was performed by patch reconstruction of the dilated aortic sinus without replacement of the ascending aorta. Microscopic examination of the diseased aortic wall revealed absence of medial elastic fibers. Late follow-up in all 4 cases revealed a normal ascending aorta with no dilatation of the aortic root and no aortic regurgitation.

Surgical management of a circumflex aneurysm with fistula to the coronary sinus

We report the successful management of a circumflex coronary artery aneurysm with fistula to the coronary sinus. Our strategy aimed at closing the fistula and grafting the obtuse marginal artery. The calcified aneurysm was left intact, and showed secondary thrombus formation on the postoperative angiogram.

Use of glue without graft replacement for type A dissections: A new surgical technique

A new surgical technique for treating type A aortic dissections is described. It consists of the exclusive and extensive use of surgical glue without replacing a segment of the ascending aorta. Since 1984, 21 patients were operated on using this technique. No operative mortality occurred and one reoperation for redissection was required. The technique is simple and safe and yields excellent short-term and long-term results.