Showing papers in "Texas Heart Institute Journal in 1999"

Cor triatriatum in adults: three new cases and a brief review.

Abstract: We report 3 cases of cor triatriatum that were diagnosed late, in the 4th and 5th decades of life. The presentations of these 2 men and 1 woman varied substantially, both in anatomic and symptomatic aspects. The woman had an associated complex congenital anomaly, which is not uncommon in cases of cor triatriatum. We present our cases, along with a review of this rare congenital cardiac anomaly.

The history and development of cardiac transplantation.

Abstract: The history of heart surgery, spanning only 100 years to date, has seen some of the most daring and persistent men and women in all of medical history. Many aspects of heart surgery, including such innovations as the heart-lung machine, aortic aneurysm surgery, and the correction of congenital heart defects, have provided future surgeons with an important lesson: diligent research can solve complex problems. The history and development of cardiac transplantation is particularly full of challenges that have been overcome, with the research phase alone spanning more than 90 years. During that time, essential contributions came from all over the world, including the United States, Russia, England, and South Africa. As is typical of medical advancement, individual contributions did not stand alone but added to the experience of those who had come before. Even so, the work of a few particular groups deserves special recognition. Most notable is the Stanford team, led by Dr. Norman Shumway, who continued to transplant human hearts when other institutions had abandoned hopes for the operation. Largely because of the commitment of that team, cardiac transplantation has become a standard option in the treatment of end-stage heart disease. Currently, only the availability of donor hearts limits the number of cardiac transplantations performed worldwide.

Treatment of congenital aneurysms of the left atrium and left atrial appendage.

Abstract: We report 2 cases of congenital aneurysm, 1 of the left atrium and 1 of the left atrial appendage. The patients were 14 and 27 years of age, respectively. Their common symptoms were paroxysmal palpitations and dyspnea. Diagnoses were suggested by chest radiographic films that revealed prominent convexity at the upper left border of the heart and were confirmed by echocardiography, which demonstrated a large cystic mass attached to the left atrium in each case. Aneurysmectomy was performed through a median sternotomy or a left thoracotomy, with cardiopulmonary bypass in 1 patient and without it in the other. Both patients were discharged, free of symptoms, in sinus rhythm. We conclude that echocardiography can provide a clear diagnosis and that aneurysmectomy is the treatment of choice.

The use of subcutaneous drains to manage subcutaneous emphysema.

Abstract: Subcutaneous emphysema is a frequent complication of thoracic and cardiac surgical procedures, and emergency tracheostomy is often advocated as the treatment for this complication. However, we report the case of a patient in whom massive subcutaneous emphysema, which had developed after emergent replacement of the aortic root, was relieved using subcutaneous drains and suction, instead of a tracheostomy. We found that the subcutaneous drains provided effective decompression of the head and neck areas, and markedly reduced airway pressure and subcutaneous air. We recommend subcutaneous drains for safe, effective, and inexpensive management of massive subcutaneous emphysema.

Myocardial protection: the rebirth of potassium-based cardioplegia.

Abstract: The introduction of open-heart surgery more than 4 decades ago signaled a new era in medicine. For the 1st time, previously untreatable cardiac anomalies became amenable to surgical therapy. The use of the heart-lung machine seemed to grant the surgeon unlimited time in which to operate inside the heart. Still frustrated by poor operating conditions and the threat of air embolism, Denis Melrose introduced elective cardiac arrest in 1955. His use of a potassium citrate solution seemed to offer a safe method to effect a quiet, bloodless field. However, a few years after its inception, numerous reports began to question the safety of this approach, and the Melrose technique was abandoned in the early 1960s. Nearly 15 years elapsed before potassium-based cardioplegia regained popularity. During this period, topical hypothermia, coronary perfusion with intermittent aortic occlusion, and normothermic ischemia were evaluated and discarded. A few European investigators like Hoelscher, Bretschneider, and Kirsch had maintained their interest in chemical cardioplegia, and it was through their efforts that future researchers like Hearse and Gay spearheaded the return to potassium-based cardioplegia, which today forms the core of the cardiac surgeon's myocardial protective armamentarium and has contributed towards lowering operative mortality rates.

Tuberculous pseudoaneurysm of the descending thoracic aorta: successful treatment by surgical excision and primary repair.

Abstract: Tuberculous pseudoaneurysm of the aorta is a rare disease with a high mortality rate We present the case of a 27-year-old woman who had a tuberculous pseudoaneurysm of the descending thoracic aorta The patient underwent successful excision and primary repair of the lesion while under hypothermic circulatory arrest and partial femoral bypass To the best of our knowledge, this is the youngest patient to be successfully treated with surgery for a tuberculous pseudoaneurysm of the descending thoracic aorta The pathogenesis, diagnosis, and treatment of this disease are reviewed, and the need to include tuberculous pseudoaneurysm in the differential diagnosis of chest lesions is emphasized

Aorto-right ventricular fistula: a late complication of aortic valve replacement.

Abstract: We report the case of a patient who was found to have an aorto-right ventricular fistula 17 years after receiving a Bjork-Shiley prosthetic aortic valve. A pseudoaneurysm had formed at the aortotomy suture line, and it had extended into the interventricular septum and had eventually opened into the right ventricle. Using transesophageal echocardiography, we identified the defect in the ascending aorta, and a left-to-right shunt. Aortography was used to confirm these findings. The pseudoaneurysm was successfully resected and the ascending aorta was replaced with a Dacron graft. To the best of our knowledge, no similar late complication of aortic valve replacement has been reported in the medical literature.

Pseudoaneurysm of the vertebral artery.

Abstract: Pseudoaneurysms of the vertebral artery are rare. Their treatment depends on the location, size, cause, and coexisting injuries. The surgical management of a 22-year-old man who had a large pseudoaneurysm in the 1st portion of the right vertebral artery is described, and an additional 144 cases from the medical literature are briefly reviewed.

Sickle cell disease and aortic valve replacement: use of cardiopulmonary bypass, partial exchange transfusion, platelet sequestration, and continuous hemofiltration.

Abstract: Sickle cell disease in patients undergoing open heart procedures presents a multitude of challenges to the medical staff. With improved techniques of cardiopulmonary bypass, surgery, and anesthesia for treating patients with sickle cell disease, perfusionists will likely encounter patients with this genetic disorder on a more frequent basis. A 40-year-old black woman was admitted to our institution with recurrent Staphylococcus epidermidis and sepsis. She underwent transesophageal echocardiography and cardiac catheterization and was subsequently diagnosed with severe aortic insufficiency. The aortic valve was replaced. Herein, we report our experience in the preoperative, perioperative, and postoperative management of this patient. We present a concise update on the current literature and techniques used by others in similar cases, and we provide a brief section on future considerations to assist fellow practitioners in recognizing this disease and meeting the accompanying challenges.

Diagnosis and treatment of concomitant aortic and coronary disease: a retrospective study and brief review.

Abstract: Coronary arteriosclerosis seriously complicates the surgical treatment of aortic diseases. The aim of our retrospective study was to determine the incidence of coronary artery disease among our surgical patients in treatment for aortic dissection or aneurysm, and to determine whether coronary intervention before aortic surgery appears to affect outcomes. Between 1 January 1993 and 1 March 1998, our center treated 253 patients for aortic dissection or aneurysm. We examined these cases retrospectively for information on diagnostic and treatment methods, both for the aortic lesions and for concomitant coronary arteriosclerosis. Aortic dissection had been detected in 86 (33.9%) patients and aortic aneurysm in 167 (66.1%). Coronary angiography was performed to search for concomitant coronary artery disease in 29 (33.8%) patients with dissection and in 112 (67.1%) patients with aneurysm; of these, 11 (12. 7%) and 54 (32.3%), respectively, were found to have coronary disease. Among 43 patients with abdominal aortic aneurysm in whom coronary angiography was performed, concomitant coronary disease was detected in 36 (83.7%). Coronary artery bypass surgery was performed in 10 patients who had dissection and in 30 patients who had aneurysm; percutaneous transluminal coronary angioplasty was performed in 7 patients who had aneurysm. Perioperative mortality rates in the dissection and aneurysm groups, overall, were 23.2% and 13.8%, respectively Unfortunately, the prospective, random clinical study that would be necessary to prove the case for or against preoperative coronary angiography among subsets of patients in need of aortic repair would raise ethical questions, given the strength of the information already in our possession, gathered by less formal methods. Our study reinforces existing evidence that preoperative angiography can reduce mortality and morbidity in the elective repair of aortic aneurysm, especially thoracic or abdominal aneurysm. However, angiography should not be performed routinely in cases of aortic dissection and should be withheld in cases of type A dissection.

Posttraumatic infrarenal abdominal aortic pseudoaneurysm.

Abstract: Posttraumatic abdominal aortic pseudoaneurysm is a rare lesion. To date, fewer than 30 cases have been reported in the literature, with most of those cases involving the suprarenal aorta. Infrarenal posttraumatic abdominal aortic pseudoaneurysm following abdominal trauma has been reported in only 6 other cases. We observed such a lesion in a 62-year-old man 15 years after blunt abdominal trauma inflicted in a car accident. Back pain was the presenting symptom. Resection and Dacron graft interposition were performed without postoperative morbidity.

Endoscopic harvesting of the greater saphenous vein for aortocoronary bypass grafting.

Abstract: We conducted an observational study to evaluate the effectiveness of an endoscopic technique for harvesting the greater saphenous vein for aortocoronary bypass grafting. We hypothesized that the endoscopic technique would minimize the risk of postoperative wound complications. From May 1997 to July 1998, we used an endoscopic technique to harvest the greater saphenous vein in 50 patients who underwent aortocoronary artery bypass grafting. Twenty-five of the patients had an increased risk for wound complications due to preexisting diabetes, obesity, peripheral vascular disease, or lymphedema. The average duration of the procedure was 39 minutes (range, 11 to 70 minutes). The average length of the harvested vein was 58 cm (range, 25 to 85 cm). We made an average of 2.5 incisions per patient (range, 1 to 5 incisions), and the average incision length was 7 cm (range, 3 to 10 cm). Two patients (4%) required conversion to an open technique using 5 small incisions. Postoperative complications included 1 wound infection (2%) and 1 small hematoma (2%). Two patients (4%) had minor erythema at the incision site, and 5 patients (10%) had postoperative lymphedema. The most common problem, ecchymosis, was seen in 6 patients (12%). None required repeat hospitalization or reoperation for wound complications. In our study, the endoscopic approach yielded superior cosmetic results, and reduced wound complications and discomfort, compared with traditional methods of vein harvesting. After gaining expertise with this minimally invasive method of vein harvesting, a surgeon can safely remove the saphenous vein in 20 to 30 minutes.

The Vineberg legacy: internal mammary artery implantation from inception to obsolescence.

Abstract: At a time when cardiac surgery was still approached with hesitation, Arthur M. Vineberg developed the procedure of direct implantation of the internal mammary artery into the left ventricle for the relief of myocardial ischemia. The Vineberg operation, as it became known, had merit but never received broad endorsement from the medical and surgical communities. Its physiologic benefits were inconsistent and for years were documented by little more than anecdotal evidence, until coronary angiography (newly developed by Mason Sones) was able to demonstrate that the procedure did in fact increase perfusion in the diseased heart. This supporting evidence came rather late, for within the next decade direct aortocoronary artery bypass grafting overtook the Vineberg operation as a more efficient means of revascularizing the myocardium. Thousands of patients, however, had benefited from internal mammary artery implantation at a time when options were few; and the procedure was an aggressive move towards current (and similarly aggressive) treatments for myocardial ischemia. Moreover, the characteristics of the myocardium that Vineberg sought to exploit may form the basis for future therapy. A reappraisal of the implant is warranted, as today's physicians and surgeons inherit the last remaining recipients of Vineberg implants.

Cardiac valvular papillary fibroelastoma: a report of 2 cases.

Abstract: Papillary fibroelastomas are rare cardiac valve tumors with potential for life-threatening complications such as stroke or sudden death. We report 2 cases of papillary fibroelastoma that were found by echocardiography. The 1st tumor arose from the mitral valve in a patient who presented after multiple transient neurologic events. The 2nd tumor arose from the aortic valve and was found incidentally during coronary artery bypass grafting. Both patients underwent successful surgical removal of the tumor.

Evolution of the ventricles.

Abstract: We studied the evolution of ventricles by macroscopic examination of the hearts of marine cartilaginous and bony fish, and by angiocardiography and gross examination of the hearts of air-breathing freshwater fish, frogs, turtles, snakes, and crocodiles A right-sided, thin-walled ventricular lumen is seen in the fish, frog, turtle, and snake In fish, there is external symmetry of the ventricle, internal asymmetry, and a thick-walled left ventricle with a small inlet chamber In animals such as frogs, turtles, and snakes, the left ventricle exists as a small-cavitied contractile sponge The high pressure generated by this spongy left ventricle, the direction of the jet, the ventriculoarterial orientation, and the bulbar spiral valve in the frog help to separate the systemic and pulmonary circulations In the crocodile, the right aorta is connected to the left ventricle, and there is a complete interventricular septum and an improved left ventricular lumen when compared with turtles and snakes The heart is housed in a rigid pericardial cavity in the shark, possibly to protect it from changing underwater pressure The pericardial cavity in various species permits movements of the heart-which vary depending on the ventriculoarterial orientation and need for the ventricle to generate torque or spin on the ejected blood- that favor run-off into the appropriate arteries and their branches In the lower species, it is not clear whether the spongy myocardium contributes to myocardial oxygenation In human beings, spongy myocardium constitutes a rare form of congenital heart disease

Intraluminal milrinone for dilation of the radial artery graft.

Abstract: There is renewed interest in the use of the radial artery as a conduit for coronary artery bypass surgery. The radial artery is, however, a very muscular artery, prone to vasospasm. Milrinone, a potent vasodilator, has demonstrated vasodilatory properties superior to those of papaverine. In this report, we describe our technique of radial artery harvesting and the adjunctive use of intraluminal milrinone as a vasodilator in the preparation of this conduit for coronary artery bypass grafting. We have used these techniques in 25 patients who have undergone coronary artery bypass grafting using the radial artery. No hand ischemic complications have been observed in this group. Intraluminal milrinone appears to dilate and relax the radial artery, rendering this large conduit spasm free and very easy to use. We recommend the skeletonization technique for radial artery harvesting and the use of intraluminal milrinone as a radial artery vasodilator in routine myocardial revascularization.

Proximal clamping levels in abdominal aortic aneurysm surgery.

Abstract: In the surgical treatment of abdominal aortic aneurysm, the single proximal cross-clamp can be placed at 3 alternative aortic levels: infrarenal, hiatal, and thoracic. We performed this retrospective study to evaluate the advantages and disadvantages of the 3 main aortic clamping locations. Eighty patients presented at our institution with abdominal aortic aneurysms from March 1993 through May 1998. Fifty of these patients had intact aneurysms and underwent elective surgery, and 30 had ruptured aneurysms that necessitated emergency surgery. Proximal aortic clamping was applied at the infrarenal level in 24 patients (22 from the intact aneurysm group, 2 from the ruptured group), at the hiatal level in 34 patients (22 intact, 12 ruptured), and at the thoracic level (descending aorta) via a limited left lateral thoracotomy in 22 patients (6 intact, 16 ruptured). Early mortality rates (within 30 days) were 4% (2 of 50 patients) among patients with intact aneurysms and 40% (12 of 30 patients) among those with ruptured aneurysms. In the 2 patients from the intact aneurysm group, proximal aortic clamps were applied at the hiatal level. In the ruptured aneurysm group, proximal aortic clamps were placed at the thoracic level in 10 patients, the infrarenal level in 1, and the hiatal level in 1. According to our study, the clinical status of the patient and the degree of operative urgency--as determined by the extent of the aneurysm--generally dictate the proximal clamp location. Patients who present with aneurysmal rupture or hypovolemic shock benefit from thoracic clamping, because it restores the blood pressure and allows time to replace the volume deficit. Infrarenal placement is advantageous in patients with intact aneurysms if there is sufficient space for the clamp between the renal arteries and the aortic aneurysm. In patients with juxtarenal aneurysms, hiatal clamping enables safe and easy anastomosis to the healthy aorta. Clamping at this level also helps prevent late anastomotic aneurysm formation, which is frequently encountered after inadvertent anastomosis of the graft to a diseased portion of the aorta. Further studies are needed in order to confirm these results.

Cardiac arrhythmia at high altitude: the progressive effect of aging.

Abstract: To evaluate the effects of aging on cardiac rhythm at high altitude, I wore a Holter monitor at age 75 during a climb to 5,100 m on Mt. Kilimanjaro, then compared findings with those from my climb to 5,895 m at age 65. Holter leads were placed to identify left or right ventricular source of ectopy, and on the 2nd ascent arterial oxygen saturation was monitored by finger oximetry. Sea-level testing revealed no evidence of cardiac disease. During ascent from 4,710 to 5,100 m, when arterial oxygen saturation reached 70%, heart rate was higher (123 vs 116 beats per minute), and frequency of left ventricular premature complexes was greater (56 vs 50 per hour) than on the earlier ascent. Nine 3- to 5-complex runs of left ventricular tachycardia were recorded during climbing, resting, or sleeping, and there was 1 run of 14 complexes at 250 beats per minute during the climb near 5,100 m. These observations suggest that aging increases sympathetic response or sensitivity, or both, to hypoxia during exercise, and even during sleep. Also, our focus should perhaps be on sympathetic stimulation rather than on pulmonary hypertension as a cause of arrhythmia in unacclimatized older persons at high altitude.

Stent implantation in an adult with coarctation of the aorta in the presence of advanced secondary heart failure.

Abstract: We report the case of a 56-year-old woman with congenital coarctation of the aorta, who presented in critical clinical condition with advanced secondary cardiomyopathy and heart failure. We successfully applied an unusual technique to pass the aortic obstruction, and then implanted a PALMAZ stent. The procedure resulted in prompt clinical improvement and completely resolved the coarctation. The patient's improved clinical condition was still evident 11 months after the procedure.

The significance of incidental noncardiac findings in Tc-99m sestamibi myocardial perfusion imaging: illustrated by a case.

Abstract: Technetium 99m sestamibi is widely used in the evaluation of myocardial perfusion imaging. Although the aim of such imaging is cardiac evaluation, numerous other organs are included in the imaging field. Failure to identify incidental abnormal findings in these organs delays diagnosis and treatment. In common with other radiopharmaceutical agents, technetium 99m sestamibi is distributed throughout the body and accumulates in multiple tissues. When interpreting studies that involve this radiotracer, the physician must be aware of its physiologic distribution, in order to recognize abnormal uptake. We present an illustrative case in which areas of decreased tracer activity were noted incidentally during the evaluation of unprocessed single photon emission computed tomography data. These findings were due to metastasis of colon cancer to the liver.

Central venous injuries of the subclavian-jugular and innominate-caval confluences.

Abstract: Injuries to the central venous system can result from penetrating trauma or iatrogenic causes. Injuries to major venous confluences can be particularly problematic, because the clavicle and sternum seriously limit exposure of the injury site. We report our institution's experience with central venous injuries of the subclavian-jugular and innominate-caval venous confluences. Significant injuries of the subclavian-jugular venous confluence frequently result from penetrating trauma, while injuries to the innominate-caval confluence are usually catheter-related. Median sternotomy provides adequate exposure of the innominate-caval confluence, while exposure of the subclavian-jugular venous confluence requires extension of the median sternotomy incision into the neck and resection of the clavicle. The literature is reviewed.

Pseudoaneurysm of the left ventricle: a rare sequela to mitral valve endocarditis.

Abstract: Pseudoaneurysms of the left ventricle are a very unusual sequela to mitral valve endocarditis. We report the case of a 62-year-old woman who developed postendocarditis submitral left-ventricular pseudoaneurysm, which was diagnosed by means of transesophageal echocardiography. The mitral valve was replaced with a prosthesis, and the mouth of the pseudoaneurysm was closed with a patch. We discuss the possible mechanism of development of this unusual sequela to mitral valve endocarditis and emphasize the diagnostic value of transesophageal echocardiography.

Hypoxia due to patent foramen ovale in the absence of pulmonary hypertension.

Abstract: In most patients with a patent foramen ovale, blood flows from the left atrium to the right atrium in the absence of pulmonary hypertension Our report describes a patient with a patent foramen ovale in whom flow occurred from the right atrium to the left atrium in the absence of pulmonary hypertension We discuss hemodynamic findings and present a brief review of the pertinent medical literature regarding this phenomenon We also discuss the role of transesophageal echocardiography in the diagnosis of this condition and in the elucidation of the underlying mechanisms, and we suggest several mechanisms that may explain the occurrence of this phenomenon in our patient

Left ventricular rupture after mitral valve replacement in a patient with osteogenesis imperfecta tarda.

Abstract: We describe the case of a patient with osteogenesis imperfecta tarda (Lobstein's syndrome) and mitral valve insufficiency. The course after mitral valve replacement was complicated by rupture of the left ventricular posterior wall, which caused massive bleeding and sudden death. The pathologic findings and the operative problems are discussed.

Chronic aneurysm of the descending thoracic aorta presenting with right pleural effusion and left phrenic paralysis.

Abstract: A 62-year-old man was admitted to the emergency department with chronic dysphagia and lower back pain. Chest radiography revealed a wide mediastinal shadow and an elevated left diaphragm, which proved to be secondary to left phrenic paralysis. The patient was diagnosed with an aneurysm of the descending thoracic aorta and was admitted to the hospital. After the patient was admitted, the aneurysm ruptured into the right chest. The patient underwent an emergency operation to replace the ruptured segment with a synthetic graft. Postoperative recovery and follow-up were uneventful. This report describes an unusual presentation of a thoracic aortic aneurysm. Hemidiaphragmatic paralysis caused by compression of the phrenic nerve is an unusual complication that, to our knowledge, has not been previously reported.