Asian Cardiovascular and Thoracic Annals

Postoperative mortality and morbidity were assessed in 75 patients with left ventricular dysfunction (ejection fraction < 35%) undergoing coronary artery bypass surgery between January 1995 and February 1999. The operative mortality was 10.7%. A rise in creatine kinase-MB isoenzyme, respiratory infection, ventricular arrhythmias, and hypotension were the most frequent complications. Of 25 variables evaluated by bivariate analysis, use of intraaortic balloon pump support, duration of intensive care stay, episodes of hypotension, low cardiac output, and deterioration of renal and liver function were associated with increased mortality. Morbidity, defined as postoperative hospital stay > 14 days, correlated with higher preoperative dyspnea class, longer cardiopulmonary bypass time, postoperative wound infection, pleural effusion, increased serum creatinine, perioperative intraaortic balloon pump support, and stroke. Postoperative low cardiac output with consequent renal failure, liver failure, and ultimately multiorgan failure, was the most important cause of mortality.

Fifteen patients with a mean age of 57 ± 17 years underwent thoracoabdominal aortic aneurysm repair under continuous selective blood perfusion of the intercostal and visceral arteries. Three aneurysms were Crawford type I, 6 were type II, and 6 were type III. Surgery was performed on an emergency basis in 5 cases. All operations were carried out using distal perfusion with mild hypothermia (> 32°C) in 13 cases and deep hypothermia (< 20°C) in 2 cases when a proximal clamp was undesirable. During aortic replacement, the intercostal arteries between the eighth thoracic and first lumbar vertebrae and the visceral arteries were reconstructed separately with a prosthetic graft under selective cold blood perfusion (22°C to 26°C). Flow was maintained above 100 mL·min⁻¹. The durations of operation, selective intercostal and visceral perfusion, and distal perfusion were 9 ± 2 hours, 70 ± 35 minutes, and 170 ± 80 minutes, respectively. There was one operative death (mortality, 6.7%) due to respiratory failure and one case of delayed paraparesis. There was no paraplegia, acute hepatorenal failure, or bowel ischemia postoperatively. This experience suggests that continuous selective cold blood spinal and visceral perfusion during thoracoabdominal aneurysm repair can provide adequate organ protection.

Ten dogs underwent 60 minutes of aortic occlusion; 5 received enoximone 10 μg·kg⁻¹·min⁻¹ and the other 5 served as controls. Distal and proximal aortic pressures were measured during the procedure. Neurological status was assessed after 72 hours. Spinal cord specimens were taken for electron microscopy. During aortic occlusion, cerebrospinal fluid pressure was 17 ± 3 mm Hg in the control group and 14 ± 4 mm Hg in the enoximone group, while distal aortic pressure was 15 ± 4 mm Hg in the control group compared to 47 ± 6 mm Hg in the enoximone group (p < 0.001). Four dogs in the control group suffered paraplegia but there was no paraplegia in the enoximone group (p < 0.01). Electron microscopy scores indicated significantly less ultrastructural damage (p < 0.01) in the enoximone group (2.73 ± 0.79) than in the control group (7.67 ± 0.89). It was concluded that enoximone was effective in reducing the risk of spinal cord injury during aortic crossclamping.

The efficacy of the right internal thoracic artery as the proximal anastomosis site in patients with a severely atherosclerotic ascending aorta was evaluated. Coronary artery bypass grafting was performed in 5 patients in whom the right internal thoracic artery was selected as the proximal anastomotic site. The graft flow in the right internal thoracic artery plus saphenous vein or radial artery graft was 52 ± 34 mL·min⁻¹ (range, 30 to 111 mL·min⁻¹). The right internal thoracic artery was found to supply adequate graft flow even to the sequential graft, in each patient. The right internal thoracic artery should be kept in mind when it is difficult to determine the best site for a proximal anastomosis in patients with severe atherosclerosis of the ascending aorta.

Between December 1997 and February 1999, 150 patients who had the left radial artery as one of the conduits for coronary artery bypass graft surgery were randomly divided into 3 groups of 50 each. Group A received a left supraclavicular block with 20 mL of 1.5% lidocaine with adrenaline (1 in 200,000), and 10 mL of 0.25% bupivacaine. Group B received intravenous diltiazem at 0.5 to 1 μg·kg⁻¹·min⁻¹ after induction and during radial artery harvest. Group C received neither the block nor diltiazem. Radial artery blood flow was measured for 20 seconds and compared between the 3 groups. All patients received diltiazem by infusion in the postoperative period for 24 hours. Radial artery take-down was abandoned in one patient in group B. There was one in-hospital death. No ischemic complication of the hand was noted. There was a statistically significant difference in mean blood flow between group B (39.20 mL/20 sec) and group C (28.84 mL/20 sec). Group A flow (34.08 mL/20 sec) was also higher than group C, but this was not statistically significant. The results advocate the use of either supraclavicular block or intravenous diltiazem during radial artery harvest.

Mitral valve annuloplasty was performed using a supporting strip or ring of polytetrafluoroethylene cut from a vascular graft. From October 1995 to September 1997, this material was used in 42 patients (mean age, 17.5 ± 5.9 years) with rheumatic mitral valve disease. The technique was found to be useful, easy, safe, cost effective, and it preserved the physiological function of the mitral valve annulus.

From September 1994 to September 1999, 50 patients underwent successful aortic valve reconstruction. Four were lost to follow-up, there were 2 early and 2 late deaths. The remaining 35 males and 11 females (mean age, 39.1 years) were followed up for 1 to 61 months (mean, 30.75 months). Most had rheumatic disease (27), the others had infective endocarditis (16) or degenerative disease (3). There was isolated aortic valve disease in 22 cases, double-valve disease in 16, triple-valve disease in 7, and 1 other. Preoperative aortic regurgitation was severe in most cases and the mean ejection fraction was 55.3%. Surgical procedures included subcommissural annuloplasty (14), cusp thinning (13), commissurotomy (10), and free-edge unrolling (10). Cusp extension with autologous pericardium was performed in 9 patients and aortic valve replacement with autologous pericardium in 22. Nine patients needed aortic valve replacement at a mean of 15.8 months postoperatively. The other 33 patients experienced marked improvements in aortic valve function. Aortic valve reconstruction is recommended in selected patients but reoperation remains an important problem. Long-term follow-up is needed to assess the role of this operation.

Between 1988 and 1998, 7 patients with coronary arteriovenous fistulas were treated surgically. Indications for surgery were congestive heart failure and marked left-to-right shunt in association with ischemic heart disease. Long-term follow-up (mean, 99 ± 37 months) was complete and mainly uneventful. Coronary arterio-venous fistulas can be successfully managed by surgery and patients should be treated without delay because complications of an untreated fistula may increase the complexity of the operation.

The occurrence of life-threatening early and late complications following the use of expanded polytetrafluoroethylene grafts for modified Blalock-Taussig shunts prompted the application of saphenous vein homografts instead. In 21 patients with cyanotic congenital heart disease, fresh saphenous vein homografts were used for Blalock-Taussig shunts from February 1998. The veins were obtained from blood-group matched patients undergoing coronary bypass grafting in the next operating room. There was no early or late mortality. Clinical and echocardiographic studies showed that all shunts were patent and functioning well at an average follow-up of 11 months. This simple homograft technique has no ischemic time and requires no chemical or antibiotic contact.

Despite advances in diagnostic and pharmaceutical therapy, a significant subset of patients with infective endocarditis require surgical intervention. Details of 44 consecutive patients operated upon for infective endocarditis from December 1990 to January 1996 were analyzed retrospectively. Patient characteristics, presentation, risk factors and microbiological epidemiology are described. The mitral valve was most commonly affected. Nearly 70% of patients had an underlying cardiac abnormality. Early mortality was 11%. Streptococcus was most frequently isolated (40% of cases), Staphylococcus aureus was found in 28% of patients and it was associated with significantly higher mortality. Prosthetic valve endocarditis accounted for 14% of cases and it was associated with significantly earlier intervention as well as a high mortality. Overall survival at 5 years was 84% with an event-free survival of 79%. Surgical intervention when valve failure develops or medical therapy is unsuccessful, is lifesaving and can be associated with acceptable morbidity and mortality. Patients with Staphylococcus aureus infection and those with prosthetic valve endocarditis require aggressive therapy including early referral for surgery.

Tracheal anastomosis was performed in 3 groups of 6 mongrel dogs each (mean age, 4 months; mean weight, 7 kg) to compare synthetic sutures. The interrupted technique was used for all anastomoses and they were evaluated by rigid bronchoscopy in the 3rd postoperative week. While suture absorption was observed in the Vicryl group, it was not visible in the Ethibond and polydioxanone groups. Dogs were sacrificed between 26 and 76 days (mean, 44 days) postoperatively. No stenosis was observed in any group. Histological evaluation of the epithelium showed a statistically significant difference in epithelization between Vicryl and Ethibond, and between polydioxanone and Ethibond. There was no difference between Vicryl and polydioxanone. These results suggest that absorbable suture material is superior for tension-free anastomoses.

From January 1986 to December 1997, 17 patients (12 males and 5 females) aged 13 to 70 years were treated for primary neoplasms of the chest wall. There were 4 cases of fibrous dysplasia, 3 each of chondrosarcoma and Askin's tumor, 2 of plasmacytoma, and 1 each of fibrosarcoma, Ewing's sarcoma, synovial sarcoma, osteosarcoma, and enchondroma. All patients, except the case of Ewing's sarcoma, underwent wide excision or debulking for unresectable tumor, and reconstruction of the chest wall. Preoperative neoadjuvant chemotherapy was given to 1 patient with osteosarcoma, radiotherapy and chemotherapy were given to 2 others. In 8 patients, the skeletal defect was reconstructed with prosthetic material. Soft tissue reconstructive procedures with various myocutaneous flaps were performed in 6 patients. None of the patients required mechanical ventilation postoperatively. There were 2 early deaths. During follow-up of 3 months to 10 years, all patients with benign tumors were free of recurrence, 2 with Askin's tumors and 1 with osteosarcoma died. Prefabricated acrylic ribs are recommended for skeletal support during chest wall reconstruction.

From 1993 to 1998, 19 patients with mediastinal tuberculosis underwent mediastinoscopy without any demonstrable parenchymal lesion and with negative diagnostic bronchoscopy. The mean age was 34.4 years (range, 15 to 67 years) and 10 were male. The most common symptom was cough in 12 patients, 4 were asymptomatic. Computed tomography showed involvement of the right paratracheal nodal station in 8 cases. Multiple biopsies of 3 to 5 mediastinal nodal stations diagnosed tuberculous lymphadenitis in 16 patients; in 5 of these, nonspecific inflammatory nodes were also sampled. In 3 patients who had biopsies of 1 mediastinal nodal station, the diagnosis could not be established. It was concluded that when used effectively, mediastinoscopy was acceptable as a final diagnostic step in patients with mediastinal tuberculous lymphadenitis.

A 66-year-old man with an aneurysm of the right coronary artery and stenotic coronary artery disease was successfully treated by lateral aneurysmorrhaphy and coronary artery bypass grafting.

Three patients with aortic coarctation and additional cardiac disease underwent a one-stage operation through a median sternotomy. Ascending-to-descending aortic bypass was carried out with a prosthetic graft in all 3 cases. One patient also had triple coronary bypass grafting with internal thoracic artery. Another patient underwent single coronary bypass grafting and aortic valve replacement. Aortic remodeling and mitral valve ring annuloplasty were performed in the third patient. There were no postoperative complications and all patients became symptom-free.

A 19-year-old man was admitted with a 6-month history of palpitations and dyspnea. A sessile myxoma of the anterior mitral valve leaflet was radically excised. Heart block developed postoperatively but the patient converted to normal sinus rhythm spontaneously during follow-up.

Two patients with univentricular physiology underwent successful surgical palliation without the use of cardiopulmonary bypass. A 19-year-old girl had an extracardiac Fontan operation and a 4-year-old boy had a Kawashima-type repair with a bilateral bidirectional Glenn procedure.

A 40-year-old man developed brucella endocarditis. Brucella melitensis was isolated from blood cultures. Echocardiography revealed flail mitral valve with ruptured chordae. Mitral valve replacement was performed and the infection was cured with tetracycline and rifampin given for 3 months after surgery.

A 42-year-old woman had left fronto-orbital aching and amaurosis for 6 months. Fluorescein angiography of the left eye showed vasculitis. Aortography revealed total occlusion of both subclavian arteries, both carotid arteries, and the left vertebral artery, with serious narrowing of the abdominal aorta. The right vertebral artery was spared. Blood flow in the middle and anterior cerebral arteries was normal in spin-echo and phase-contrast magnetic resonance studies. Immuno-histochemical findings indicated Takayasu's arteritis.

Aortocaval fistula is a rare complication of rupture of an aortic aneurysm into the inferior vena cava. Prompt surgical repair is mandatory for salvage. Emergency surgery was performed in 2 cases of aortocaval fistula. The underlying etiology was polyarteritis nodosa in one patient and atherosclerosis in the other. Polyarteritis nodosa leading to abdominal aortic aneurysm with aortocaval fistula is reported for the first time.

A 14-year-old boy was investigated for unexplained tachycardia and multiple pulmonary emboli demonstrated by computed tomography. A right ventricular hydatid cyst was diagnosed by echocardiography and successfully excised under cardiopulmonary bypass.

A 68-year-old man underwent coronary angiography for postinfarction angina, which revealed right coronary artery stenosis and a mass in the left ventricle. Transesophageal echocardiography showed a large blood cyst originating from the anterior papillary muscle of the mitral valve. Coronary artery bypass grafting was performed and the cyst was successfully excised.

Superior vena cava syndrome due to infradiaphragmatic tumor metastasis was detected in a 70-year-old man. A tumor attached to the right atrial wall was excised and subsequent transurethral resection of a bladder tumor revealed high-grade transitional cell carcinoma. The disease progressed and the patient died 6 months later.

A 54-year-old man presented with cough, breathlessness, and fatigue. Echocardiography showed multiple masses in the left atrium, right atrium, and left ventricle. The patient underwent emergency surgery with a diagnosis of multicentric myxoma. Postoperative histopathology showed squamous cell carcinoma.

A 72-year-old woman underwent replacement of the ascending aorta because of acute aortic dissection. During surgery, the right pulmonary artery was injured. Direct suture closure led to pulmonary artery stenosis with elevated central venous pressure and recurrent ventricular fibrillation. Extracorporeal membrane oxygenation stabilized her hemodynamic condition. She was weaned from the device 6 days later. Pulmonary angiography revealed severe obstruction of the right pulmonary artery but she had no respiratory symptoms thereafter.

Computed tomography in 2 patients with constrictive pericarditis and history of tuberculosis showed pericardial thickening and calcification, inferior vena caval dilation, enlarged atria, and small tubular ventricles. Computed tomography accurately differentiated constrictive pericarditis from restrictive cardiomyopathy. Successful pericardiectomy was carried out in both cases.

Between April 1996 through March 1999, 15 patients with severe (> 60%) left main coronary artery stenosis became hemodynamically unstable on induction of anesthesia, in spite of optimal pharmacological management. Retrograde coronary sinus perfusion was instituted soon after the median sternotomy to improve hemodynamics until the establishment of cardiopulmonary bypass after harvesting internal mammary artery and saphenous vein grafts.

This technique using only 3/0 polypropylene suture, provides reconstruction appropriate to the anatomy and physiopathology of functional tricuspid insufficiency. Problems such as the gliding effect, pannus formation, and infection, should be minimal. The technique was successfully applied in 3 patients.