Zvi Adler

Myocardial protection in operations requiring more than 2 h of aortic cross-clamping

OBJECTIVEnLong periods of aortic cross-clamping time during cardiac surgery are associated with high rates of morbidity and mortality because of damage to the myocardium. Recently, we have used a method of myocardial protection based on the principles of hyperkalemic cardioplegic arrest. We use antegrade administration of warm, undiluted blood followed by continuous retrograde infusion of tepid, undiluted blood supplemented with potassium and magnesium. In this study, we have retrospectively reviewed our experience with this method of cardioprotection in operations requiring more than 2 h of cross-clamp time.nnnMETHODSnWe retrospectively reviewed the medical records of 1280 patients who underwent myocardial revascularization, valve repair or replacement, or a combination of both operations between January 1, 1994 and December 31, 1997. Patients were divided into two groups: the short cross-clamp group (SXC) (n = 1144) had cross-clamp times < 120 min (mean, 78 +/- 20 min; range, 35-119 min) and the long cross-clamp group (LXC) (n = 136) had cross-clamp times > 120 min (mean, 154 +/- 31 min; range, 120-277 min). We compared preoperative, operative, and postoperative variables between the two groups.nnnRESULTSnSignificantly more patients in the long cross-clamp group (43.4%) underwent the combined operation than in the short cross-clamp group (2.3%), and the rate of reoperation was significantly higher in the long cross-clamp group (12%) than in the short cross-clamp group (5%). Despite these differences in operative complexity, we found no difference in hospital mortality rates between the two groups. The only significant postoperative differences were that the long cross-clamp group had a greater need for inotropic agents (43 vs. 29%), higher serum levels of creatine kinase (880 +/- 583 vs. 613 +/- 418) and CK-MB (10.9 +/- 6.4 vs. 5.9 +/- 5.2), and a longer hospital stay (9.6 vs. 6.1 days).nnnCONCLUSIONnLong, complex operations requiring more than 2 h of cross-clamping can be performed safely with our method of cardioprotection based on continuous retrograde infusion of tepid, hyperkalemic, undiluted blood.

Spontaneous echocardiographic contrast with the carbomedics mitral valve prosthesis

Abstract Spontaneous echocardiographic contrast is a well-known, although poorly understood, phenomenon that has been occasionally noticed in patients with low flow states such as the echoes seen in the left atrium in patients with mitral valve disease, 1 in the left ventricle in severe left ventricular systolic dysfunction 2 or in the inferior vena cava of patients with constrictive pericarditis. 3 There are rare reports on spontaneous contrast in patients with mechanical prosthetic mitral valves. 4–6 Compared with the more common smoke-like contrast observed in low flow states, spontaneous echoes in patients with mechanical mitral prosthetic valves are bright and high velocity but scanty.

Effect of Preoperative Antibiotic Prophylaxis on Surgical Site Infections Complicating Cardiac Surgery

OBJECTIVEnTo evaluate the effect of an optimized policy for antibiotic prophylaxis on surgical site infection (SSI) rates in cardiac surgery.nnnDESIGNnProspective cohort study.nnnSETTINGnTertiary medical center in Israel.nnnMETHODSnSSIs were recorded during a 10-year study period and ascertained through routine surveillance using the National Healthcare Safety Network (NHSN) methodology. Multivariable analyses were conducted to determine which significant covariates, including the administration of preoperative prophylaxis, affected these outcomes.nnnRESULTSnA total of 2,637 of 3,170 evaluated patients were included, and the overall SSI rate was 8.4%. A greater than 50% reduction in SSI rates was observed in the last 4 years of the study. Overall and site-specific infection rates were similar for patients receiving cefazolin or vancomycin. SSIs developed in 206 (8.1%) of the 2,536 patients who received preoperative prophylaxis (within 2 hours of the first incision) compared with 14 (13.9%) of 101 patients who received antibiotic prophylaxis at a different time (P = .04; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.0-3.3). After accounting for covariates, preoperative hospital stay (5 days or more), an NHSN risk category (2 or 3), age (60 years or more), surgeons role, and the period of measurement were significantly associated with SSIs. Emergency surgery, age, surgeons role, and nonpreoperative prophylaxis were found to be independent predictors of superficial SSI.nnnCONCLUSIONSnWe observed a progressive and significant decrease in SSI rates after the implementation of an infection control program that included an optimized policy of preoperative prophylaxis in cardiac surgery.

Ventricular septal rupture complicating myocardial infarction: Comprehensive assessment of cardiac coronary arteries, anatomy, perfusion and function by multidetector computed tomography

38-year-old man was referred for electrocardiogram (ECG)-gated multidetector computed tomography (MDCT) coronary angiography following detection of ventricular septal rupture (VSR) on transthoracic echocardiography 24 h after admission for an acute inferior wall myocardial infarction. He had been treated with primary angioplasty and stenting of a tight distal right coronary stenosis. Detailed, comprehensive evaluation of the VSR, myocardium and coronary arteries was performed with ECG-gated MDCT coronary angiography using a Brilliance 16-slice scanner (Philips Medical Systems, USA). MDCT coronary angiography showed a patent stent and a proximal heterogeneous plaque of borderline significance (Figure 1). The measured global left ventricular function, using the MDCT data, disclosed a mildly reduced ejection fraction of 47%. Regional functional analysis using cine films of the MDCT data depicted regional akinesis of the inferior and inferoseptal mid- and basal segments, manifesting as a marked reduction in myocardial thickening during systole (Video 1 – click here to view). Furthermore, first-pass myocardial perfusion analysis depicted a well-defined, nearly transmural enhancement defect parallel to the akinetic myocardial region (Figure 2). Further detailed analysis of the interventricular septum at end-diastole showed a full-thickness rupture in the mid-inferior septum (Figures 3A and 3B). Of note, the septal rupture occurred at the junction of the normally enhancing anterior septum and the hypoperfused, necrotic, inferior septum and inferior myocardial segments, indicating that this junction line appears to act as a locus minoris resistentiae. The VSR demonstrated near-complete lumen obliteration during peak systole (Figures 3A and 3B), suggesting that at least part of the bordering myocardium (anterior septum) was contracting and, thus, viable. Because the described VSR was small and of no hemodynamic significance, based on imaging findings, it was managed conservatively with follow-up echocardiography. There was no change during a three-month follow-up period.

Punch Pulmonary Valvectomy: Another Alternative to Treat Critical Pulmonary Stenosis

For neonates with severe valvar stenosis, or valvar pulmonary atresia with an imperforate pulmonary valve, we present a simple but effective closed procedure using a specially designed valvectomy punch. Seven neonates, who were not suitable for any type of transcatheter procedure, were treated. There were two late deaths, neither directly related to the operation; 4 patients are developing well. This approach using the valvectomy punch is a fast, safe, and effective procedure.

No-react anticalcification tissue treatment results with stentless heart valves in two adolescents

J Thorac Cardiovasc Surg Lorber and Shimon Reisner Simcha Milo, Zvi Adler, Yaron Bar-El, Victor Kertsman, Shtewee Sawaed, Abraham STENTLESS HEART VALVES IN TWO ADOLESCENTS NO-REACT* ANTICALCIFICATION TISSUE TREATMENT RESULTS WITH http://jtcs.ctsnetjournals.org/cgi/content/full/117/6/1222 the World Wide Web at: The online version of this article, along with updated information and services, is located on