Surgical removal of stent entrapped in proximal left coronary artery system

Coronary artery stents were developed to prevent acute coronary closure and reduce restenosis after coronary angioplasty. A well-recognized, although uncommon, complication of stent deployment is loss of control, resulting in the stent being inadvertently deployed in an undesirable location. This case study describes a patient who underwent stent insertion to the left anterior descending artery and had stent entrapment in the left anterior descending/left main coronary artery. The stent was surgically removed, preventing unnecessary bypass grafting to a normal circumflex artery.

Is the heart a source for elevated circulating endothelin levels during aorta-coronary artery bypass grafting surgery in human beings?

Reports have shown increased systemic levels of endothelins during coronary artery bypass grafting in human beings. It was not known whether increased endothelin levels during coronary artery bypass grafting reflect a general systemic response to the surgical procedure or increased myocardial production of endothelins in response to ischemia and reperfusion. We therefore measured endothelin levels in the right atrium and proximal aorta of 15 patients undergoing coronary artery bypass grafting for anginal syndrome immediately before aortic crossclamping and again after cessation of cardiopulmonary bypass. In five patients, we also measured coronary sinus levels of endothelins during cardiopulmonary bypass circulation. We found that endothelin levels were elevated throughout the surgical procedure. Right atrial endothelin levels were significantly elevated after cessation of cardiopulmonary bypass circulation with respect to values immediately before aortic crossclamping (11.1 +/- 3.1 vs 14.2 +/- 3.7 pg/ml, p = 0.008), whereas endothelin levels in the proximal aorta did not rise significantly (10.5 +/- 2.3 vs 11.6 +/- 2.4 pg/ml, p > 0.5). Coronary sinus endothelin levels tended to decline temporarily during cardiopulmonary bypass circulation (11.1 +/- 2.1 pg/ml before aortic crossclamping, 7.9 +/- 1.9 1 minute after release of aortic crossclamp, and 9.9 +/- 2.1 pg/ml after release of partial aortic crossclamping, p = 0.06). We conclude that the rise in right atrial endothelin levels during coronary artery bypass grafting reflects systemic production and secretion of endothelins, probably by vasculature or organs distal to the proximal aorta, and is not the result of increased myocardial production and secretion of endothelins.

Individual anatomy demands various techniques in correction of an anomalous origin of the left coronary artery in the pulmonary artery

Anomalous origin of the left coronary artery (ALCA) from the pulmonary artery is a rare cardiac anomaly. It can result in decreased myocardial perfusion and impaired left-ventricular function, which can lead to congestive heart failure or even myocardial infarction. Reconstructive surgery of the left coronary artery is the desirable measure in the management of this anomaly. Since July 1992, five patients with ALCA from the pulmonary artery were treated surgically. Age at operation ranged from 3 months to 11 years. Three patients had congestive heart failure and one was in cardiogenic shock. Operative techniques included "tunnel type" surgery in three cases and aortic reimplantation in two. Two operative variations performed successfully in this series are described. There were no postoperative deaths. At the latest follow-up (mean 14 months), all anastomoses were patent and showed antegrade flow. For those patients with ALCA from the pulmonary artery, direct reimplantation of the ALCA to the aorta is the most physiologically appropriate reconstructive solution, and offers good early and late results. Intrapulmonary tunnel from aortopulmonary window to coronary artery is recommended for children in whom aortic reimplantation is not anatomically feasible.

Definitive repair of tetralogy of fallot. A review of 104 cases

Definitive repair of tetralogy of Fallot was performed on 104 children, including 42 younger than 2 years (24 < 1 year and 7 < 6 months). Twenty-two had previous shunt. Transannular patching was required in 60 cases and conduit grafts in two. During 60-day postoperative observation, five patients died. Of the 99 survivors, 93 recovered without complications, three required prolonged mechanical ventilation, two reoperation and one balloon dilatation for residual left pulmonary artery stenosis. Morbidity and mortality were not significantly higher in the patients younger than 12 months, although transannular patching was more common in that age group. Previous shunt operations entailed higher prevalence of distal stenosis and distortion of the pulmonary arteries, which often necessitated surgical repair, and also considerably increased postoperative morbidity and mortality. As the outcome in definitive repair of Fallot's tetralogy is favourable, even in patients younger than 12 months, and as preliminary shunt operations are associated with heightened perioperative morbidity and mortality rates in definitive repair, we advocate the definitive operation for all young patients with severe cyanosis or cyanotic spells.

Repeated repair of tetralogy of Fallot. Report of 11 cases and review of the literature

Eleven patients underwent late repeated correction of tetralogy of Fallot in 1991-1993. The previous operation was repair of simple Fallot's tetralogy in seven cases, repair plus transannular patch in one case and repair of tetralogy and pulmonic atresia in three cases. The indications for reoperation were residual ventricular septal defect, right ventricular outflow tract (R.V.O.T.) obstraction, residual branch pulmonary artery stenosis, aneurysmal dilatation of R.V.O.T. Patch or combination of any of the above. At reoperation these defects were corrected. The post operative course was uneventful in eight patients. Two required mechanical ventilation for 2-3 days, and one underwent another operation for residual branch pulmonary artery stenosis. The functional and haemodynamic results were good in ten patients, and one had residual distal pulmonary artery stenosis. There were no death during 2 years of follow-up. Repeated correction of tetralogy of Fallot thus had low postoperative morbidity and good haemodynamic results. For the relatively few patients initially found to have tetralogy of Fallot and pulmonic atresia, the outcome may be less favorable.

Cardiac surgery in octogenarians

Age as an important risk factor in surgery has always been debatable. Between January 1991 and December 1992, 35 consecutive octogenarian patients (23 males and 12 females; average age 82.3 years) were retrospectively evaluated. Twenty-five patients had only coronary artery by-pass graft operations (CABG), five had aortic valve replacements (AVR) and five had combined AVR-CABG operations. Twenty-five of the 30 patients (83%) who underwent CABG alone or a combined procedure had suffered from unstable angina. The mean ejection fraction was 40% in this group. An average of 2.8 grafts per patient was performed. The left internal mammary artery (LIMA) was-used in nine patients (30%). The average hospitalization period was 11.5 days. Operative mortality (within 30 days) was zero. Patients who underwent AVR only were hospitalized for an average of 17.6 days and there were two cases (6%) of mortality in this group. All patients who underwent AVR and CABG were discharged within 14 days. Overall complications occurred in nine patients (25.7%); cardiac arrythmias, (4) neurological deficits (2), severe wound infections (2), and adult respiratory distress syndrome (1). The use of the LIMA was not associated with an increased incidence of bleeding or sternal infection. The low rates of mortality and major complications lead us to conclude that, when indicated, surgical treatment including the use of LIMA in selected cases, should be offered to this group of patients, even in the presence of moderate LV dysfunction.

Total cavopulmonary connection (TCPC) for complicated congenital heart malformations

We reviewed our experience with 40 patients who had undergone total cavopulmonary connection (TCPC) during the past three years. Thirty-one patients had functional single ventricle; only 8 of these with tricuspid atresia, five patients had complex forms of double outlet right ventricle (DORV), and four complex A-V canal. Previous palliative procedures, mostly systemic-pulmonic shunts, were performed in 34 patients. Concomitant procedures were required in 18 patients, mainly reconstruction of distorted pulmonary arteries. A subgroup of 14 high risk patients, that did not fulfil the classical Fontan criteria, underwent 4 mm fenestration of the intra-atrial baffle. There were three (7.5%) early postoperative deaths which occurred in the higher risk group (fenestrated group). However, the remaining patients were all in functional class I or II. Total cavopulmonary connection provides reasonably good definitive palliation for patients with single ventricle physiology. Fenestration of the intra-atrial baffle increases the number of candidates suitable for the Fontan procedure, although the exact inclusion criteria for these patients has yet to be defined.

Total cavopulmonary connection for complicated congenital heart malformations

We reviewed our experience with 40 patients who had undergone total cavopulmonary connection during the past 3 years. Thirty-one patients had functional single ventricle, only 8 with tricuspid atresia; five had complex forms of double outlet right ventricle, and 4 complex A-V canal. Previous palliative procedures, mostly systemic-pulmonic shunts, were performed in 34 patients. Concomitant procedures, mainly reconstruction of distorted pulmonary arteries, were required in 18 patients. A subgroup of 14 high risk patients, who did not fulfil the classical Fontan criteria, underwent 4 mm fenestration of the intraatrial baffle. There were 3 (7.5%) early post-operative deaths that occurred in the higher risk group (fenestrated group). However, the remaining patients were all in functional class I or II. Total cavopulmonary connection provides reasonably good definitive palliation for patients with single ventricle physiology. Fenestration of the intraatrial baffle increases the number of candidates suitable for the Fontan procedure, although the exact inclusion criteria for these patients has yet to be defined.

Tumour promoters/protein-kinase C activators augment the survival and function of human monocyte-derived macrophages in long-term cultures

In this study the effect of various Protein kinase C (PKC) activators/tumour promoters on the maturation and activity of human peripheral blood monocytes was examined. Monocytes were cultured in the absence or presence of various PKC activators for up to 2 weeks, and examined for the number of adherent cells, expression of myeloperoxidase enzymes, CD14 antigens, mannose/N-acetylglucosamine (Man/GlcNAc) receptors, and the production of TNF-alpha. The presence of PKC activators in cultures of monocyte-derived macrophages (HuMoDM) prevented the loss in the number of initially plated monocytes, otherwise observed in long-term tissue cultures with time of incubation. This effect of PKC activators on monocyte survival was diminished in the presence of PKC inhibitors. HuMoDM obtained in the presence of PKC activators maintained a normal differentiation pattern, as was evident by the loss of granular myeloperoxidase enzymes and CD14 antigens, and the acquisition of membrane Man/GlcNAc receptors. HuMoDM which differentiated in the presence of PKC activators also released TNF-alpha in comparable amounts to freshly harvested human monocytes. PKC activators/tumour promoters augmented the viability of long-term cultures of human monocyte-derived macrophages. Such macrophages may facilitate cell and molecular biology studies of differentiated human macrophages.

Late outcome of valve replacement with the Cross-Jones caged-lens prosthesis

A 58 year old woman underwent re-replacement of a Cross-Jones caged-lens mitral prosthesis 23 years after the first operation. She represented one of the 38 patients who received 42 Cross-Jones prostheses two decades earlier. Continued adequate performance for more than two decades in five patients bears a surprising testimony to the longevity of this historic low profile prosthesis.