Impact of preoperative hemodynamic optimization on right ventricular failure after left ventricular assist device implantation

Background

Preoperative hemodynamic parameters are linked to higher rates of right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation. It is unclear if preoperative hemodynamic optimization decreases the incidence of RVF after LVAD.

Methods

Single-center retrospective analysis of consecutive LVAD recipients between 2015 and 2020. Pre-operative right heart catheterization and a strategy of hemodynamic optimization were performed in all patients. Pre-operative right ventricular dysfunction (RVD) was defined by a CVP ≥16 mmHg and pulmonary artery pulsatility index (PAPi) <1.85. The optimization goal was defined as CVP <16 mmHg, PAPi ≥1.85, and Cardiac Index of ≥2.0. The main outcome was RVF (inotropes >14 days, discharge on home inotropes, or right ventricular mechanical support device).

Results

128 LVAD recipients (age 58 years, 74% male, 68% had non-ischemic cardiomyopathy, 45% were on home inotropes, HeartMate 2 in 61%, HeartMate 3 in 31%, and HVAD in 9%) were analyzed. Pre-operative RV dysfunction was present in 48% and these patients were younger, with higher rates of home inotropes, and intra-aortic balloon pump (IABP) pre-LVAD. Postoperative RVF occurred in 60% of patients with RV dysfunction and 40% of the patients without pre-operative RV dysfunction (p<0.002). 40% of patients with RV dysfunction achieved RV optimization goals (32% required IABP). Among those, 53% developed RVF-Post LVAD. RVF was numerically but not significantly higher among those with RV dysfunction who achieved hemodynamic goals (66% vs. 34%, p=0.37) vs. those that did not. Patients with RVF-post LVAD had 10% (n=5) in-hospital mortality.

Conclusion

Pre-LVAD RV dysfunction based on hemodynamic markers is associated with RVF after LVAD implantation. In patients with RV dysfunction, a strategy of pre-LVAD “optimization” to achieve RV hemodynamic optimization goals did not affect the incidence of post-operative RVF.

Funding Acknowledgement

Type of funding sources: None.

Changing demographics, temporal trend in waitlist and post-transplant outcomes after heart transplantation in the United States: analysis of unos database 1991–2019

Background

The landscape of heart transplantation (HT) has changed significantly with respect to patient selection, surgical techniques, and patient outcomes. We sought to investigate temporal trends in patient characteristics, waitlist and post-transplant outcomes after HT in the U.S.

Methods

We queried the national database of the United Network of Organ Sharing (UNOS) to identify adults listed for HT in the U.S. between 1991 and 2019. Patients were divided into four eras based on the three time points in which changes were made to the patient selection/allocation policy (1999, 2006, and 2018), and patient characteristics as well as waitlist and post-transplant outcomes were evaluated for each era.

Results

Between 1991 and 2019, a total of 95,179 patients were added to the waitlist for HT in the U.S. Compared to era 1, patients listed in era 4 were older (mean age: 52.4 years), more female (27.6%) and ethnic minorities (40%), and with higher-risk comorbidities (28.8% diabetes, 35.6% obese). Over the study period, there were 22,070 waitlist deaths and 61,687 transplants.

Compared to the preceding era, there was significant decrease in waitlist mortality in the last 2 eras (e.g., sub-hazard ratio for era 4 vs era 3 =0.37, 95% CI=0.32–0.44). For each year, only 27.1% to 40.5% of those on the waitlist were transplanted. Among those who were transplanted, there was increase in the rates of in-hospital stroke (2.8% in era 1 to 3.7% in era 4), renal failure requiring dialysis (7.2% to 17.1%), and hospital length of stay (14 to 17 days), p-values<0.001 for all. However, this has not negatively impacted short-term survival when compared to the preceding era (1-year graft survival = 89.7% in era 4). Based on a projection model, we predict a 47% increase in living adult heart transplant recipients to to 44,366 in 2040.

Conclusion

There have been significant changes in the characteristics of patients listed for HT in the U.S., including an increasing proportion of high-risk co-morbidities. Although the transplant volume has increased, the wide supply-demand gap persisted. The last 2 changes in the allocation policy in 2006 and 2018 achieved their primary objective of reducing waitlist mortality.

Funding Acknowledgement

Type of funding sources: None.

Antegrade Cardioplegia Decannulation Made Simple With the Cor-Knot System: Technique and Tips After 20 Consecutive and Controlled Patients

Closing the cardioplegia cannulation site can be challenging in minimally invasive video-assisted cardiac surgery. The Cor-Knot system is used to tie down valve sutures within the heart efficiently, although erosions to neighboring structures are reported. We hypothesized that a modification of the Cor-Knot system could enable safe hemostasis of the cardioplegia aortic root site and avoid erosions of the aorta or right atrium. This is a single-arm prospective study including 20 consecutive patients operated through a video-assisted method at our clinic between January 2019 and February 2019. At the end of the procedure, the suture was passed through a Cor-Knot device and crimped on a band of Teflon-felt. The two tips of the Teflon-felt toward the right atrium were put together and tightened with a 5/0 Prolene suture in order to protect the sharp ends of the device. Hemostasis was achieved using the technique in all 20 patients, with no requirement for further suture placement to ensure hemostasis of the cardioplegia cannulation site. The device was protected from the right atrial appendage and there was no bleeding. At 6-month follow-up, no patients required a reoperation for aortic or right atrial erosion. The Cor-Knot system was used off-label to close the cardioplegia cannulation site in minimally invasive surgery. This appears safe and effective in our initial 20-patient experience.

Measures of Neural Similarity

One fundamental question is what makes two brain states similar. For example, what makes the activity in visual cortex elicited from viewing a robin similar to a sparrow? One common assumption in fMRI analysis is that neural similarity is described by Pearson correlation. However, there are a host of other possibilities, including Minkowski and Mahalanobis measures, with each differing in its mathematical, theoretical, and neural computational assumptions. Moreover, the operable measures may vary across brain regions and tasks. Here, we evaluated which of several competing similarity measures best captured neural similarity. Our technique uses a decoding approach to assess the information present in a brain region, and the similarity measures that best correspond to the classifier’s confusion matrix are preferred. Across two published fMRI datasets, we found the preferred neural similarity measures were common across brain regions but differed across tasks. Moreover, Pearson correlation was consistently surpassed by alternatives.

Video-assisted cardiac myxoma resection: basket technique for complete and safe removal from the heart

Video assistance can replace sternotomy in cardiac operations with excellent results. Because myxomas are very friable tumors, their removal from the heart and chest cavity through a working port in video-assisted or robotic procedures may be challenging. We used a laparoscopic basket to safely catch and remove these friable tumors in 10 patients undergoing video-assisted myxoma resection between December 2008 and June 2011. Complete excision and removal was achieved in all patients. No neurologic, vascular, or wound complications were observed. This minimally invasive myxoma technique gives excellent and reproducible results without a higher risk for the patient.

Pericardial synovial sarcoma of the heart; is it always worth operating?

Synovial sarcoma is a rare malignant soft-tissue tumor that most commonly occurs in the extremities of young adults. Primary pericardial synovial sarcoma is extremely rare. We report the case of a 37 year old male patient who presented with intermittent fever, nocturnal sweating and asthenia. Chest X-ray revealed an enlarged cardiac silhouette. Echocardiography identified pericardial effusion and a mass compressing the right ventricle. After percutaneous drainage of the effusion, the mass was not visible and deemed to have been septations of the effusion. Chest computed tomography (CT) did not show the mass visible on the X-ray. At one month follow-up, the pericardial mass was again visible on echocardiography and confirmed by magnetic resonance imaging (MRI). CT-guided biopsy showed malignant mesenchymal cells. Complete resection was attempted, but not possible due to diffuse infiltration of the epicardium. Histological examination of the resected tissue revealed an undifferentiated primary pericardial synovial sarcoma. The patient refused adjuvant treatment and died 15 days later. Surgical resection is considered the cornerstone of treatment of this rare type of malignant tumor of the young; our patient presented with a diffusely infiltrating tumor which could not be resected and required reoperation for tamponade and left pericardectomy. We question whether the choice to attempt resection was beneficial.

Thoracoscopic and robotic tricuspid valve annuloplasty with a biodegradable ring: an initial experience

BACKGROUND AND AIM OF THE STUDY

Ring annuloplasty is a technically demanding and time-consuming thoracoscopic and/or robotic surgery. The initial experience of the authors with the intra-annular Bioring tricuspid ring using a minimally invasive access is reviewed, and some modifications are proposed to adapt to the particularities of these approaches.

METHODS

Patients undergoing minimally invasive tricuspid annuloplasty were included prospectively between March and September 2008. The feasibility and ease of implantation were evaluated. A total of 10 patients (six females, four males) was included (eight with functional regurgitation, two with endocarditis). Six patients underwent surgery through a small anterolateral thoracotomy, and the da Vinci S robotic system was used in four cases.

RESULTS

The mean cardiopulmonary bypass and aortic cross-clamp times were 123 +/- 30 min and 86 +/- 28 min, respectively. Ring implantation was successful in all patients. There was one late death from multiple organ failure. None of the patients required reoperation. At discharge from hospital, seven patients had no or discrete tricuspid regurgitation (TR), and two had moderate TR with no tricuspid stenosis but remained stable during the follow up period.

CONCLUSION

The biodegradable Bioring offers a simple and quick implantation which is feasible and simplified in minimally invasive approaches.

Cardiac autotransplantation for aortic and mitral valve replacement in a patient with nephrogenic systemic fibrosis

Adequate exposure is a prerequisite for open valve surgery. The mitral valve can rarely be very challenging to expose. We describe a redo double valve replacement in a patient with nephrogenic systemic fibrosis in whom exposure of the mitral valve was achieved with cardiac autotransplantation.

Reduction of postoperative hypothermia with a new warming device: a prospective randomized study in off-pump coronary artery surgery

Hypothermia has been used for decades in cardiac surgery to limit the ischemic insult to the heart. With the diffusion of off-pump coronary artery surgery, the practice of arresting and cooling the heart has been abandoned. At University of Miami Miller School of Medicine, we tested a new warming device by performing a prospective study in which 50 patients were randomized to either the use of the Kimberly-Clark warming system or to standard methods of control of body temperature. The two groups were compared in terms of core body temperature (CBT), intra- and postoperative blood loss, blood products transfusions, extubation time, intensive care unit (ICU) and hospital length of stay and incidence of infections. Five patients in the control group and 0 patients in the study group dropped their CBT below 35 degrees C during the operation (P<0.01). Total blood loss, measured in terms of cell-saver and chest tube drainage, was 27 % and 14 % less for the study group (P<0.01). Hospital length of stay was 1.2 day less in the study group (P<0.01). The Kimberly-Clark Patient Warming System allowed for better control of core body temperature during off pump coronary artery bypass surgery compared to traditional techniques. This translated in less intra and postoperative blood loss and shorter hospital length of stay. Other advantages, such as decreased blood-products transfusions, decreased incidence of infections, decreased ICU length of stay and overall reduction of costs might be evident on larger study groups.

Impending paradoxical embolism: systematic review of prognostic factors and treatment

BACKGROUND

Little is known about the optimal management of impending paradoxical embolism (IPDE), a biatrial thromboembolus caught in transit across a patent foramen ovale. Our aim was to review observational studies on this subject to identify prognostic factors and to compare mortality and systemic embolism between treatments.

METHODS

Systematic literature searches in Medline, Embase, and Cochrane Library identified 154 studies (174 patients). The primary end point was 30-day mortality. The secondary end point was systemic embolism during treatment.

RESULTS

Thirty-day mortality was 18.4%. On univariate analysis, age (64+/-13.9 vs 56.7+/-16.5; P = .01), coma (12.9% vs 2.2%; P = .02), and systemic embolism (71.9% vs 51.4%; P = .048) at presentation were significantly increased among nonsurvivors. Surgical thromboembolectomy had lower mortality than other treatment groups (10.6%; P = .04). In multivariable models, no prognostic factor was a significant independent predictor of mortality. Surgically treated patients had nonsignificantly reduced mortality (odds ratio [OR], 0.65 [0.24-1.72]; P = .65) and thrombolysis-treated patients had increased mortality (OR, 1.62 [0.43-5.97]; P = .47). However, systemic embolism during treatment and combined mortality and systemic embolism was decreased in the surgery group (OR, 0.13 [0.03-0.67]; P = .02 and OR, 0.26 [0.11-0.60]; P = .001).

CONCLUSIONS

This review attempts to help guide what to do in IPDE, despite severe limitations of the methods. Surgical thromboembolectomy showed a nonsignificant trend toward improved survival, significantly reduced systemic embolism, and composite of mortality and systemic embolism, compared with anticoagulation alone. Thrombolysis, on the other hand, had the opposite effect, although not significantly.

Life-threatening pulmonary embolism associated with a thrombus straddling a patent foramen ovale: report of a case

BACKGROUND AND AIM

A biatrial thrombus straddling a patent foramen ovale (PFO) is rare. The optimal management is controversial. This report offers an additional report and brief review of the literature.

CASE REPORT

A 72-year-old female presented with paroxysmal dyspnea. Transthoracic echocardiography showed distended right heart cavities, pulmonary artery hypertension, and a thrombus in the right atrium passing through the PFO into the left atrium. Urgent surgical embolectomy confirmed an 11.5 cm serpentine biatrial thrombus and allowed PFO closure and bilateral pulmonary embolectomy. Postoperative recovery was uneventful.

CONCLUSIONS

The risk of systemic embolization during thrombolytic or heparin treatment for biatrial thrombus makes most authors recommend surgical or interventional thrombectomy and PFO closure. Given the limited number of cases, there is no evidence that any of the treatment strategies provide a better survival.

Aortic Arch Repair and Cold-Reactive Agglutinins: What to Do?

We describe a modified perfusion technique for aortic arch repair under mild hypothermia and continuous cerebral and systemic perfusion.

One-stage repair with a new integrated stent-Dacron prosthesis for type B aortic dissection

We describe one-stage repair for a dilated chronic type B aortic dissection in a 55-year-old man by means of a new integrated stent-graft-Dacron prosthesis (Jotec, Hechingen, Germany).

Late retrograde aortic perforation by the uncovered part of an endograft: an increasing complication

A 56-year-old man, known for type B aortic dissection, was treated 3 years before with a Talent endograft (Medtronic, Minneapolis, USA) in the descending aorta. He presented with tamponade caused by the perforation of the aortic intima by the uncovered stent strut. The ascending aorta and part of the aortic arch were replaced. The operation and recovery were uneventful. To avoid aortic arch damage by thoracic stent-grafts, the proximal stent should be fully covered. In addition we should be very cautious about the proximal landing zone of the stent, which should not be on the curved portion of the aorta.

Axillary cerebral perfusion for arch surgery in acute type A dissection under moderate hypothermia

BACKGROUND

Aortic arch surgery is still associated with increased mortality and morbidity especially in acute type A aortic dissection. Adequate brain protection is essential and commonly performed by either antegrade selective perfusion of the brachiocephalic arteries or an interval of profound hypothermic circulatory arrest. We present our experience for open aortic arch repair with continuous antegrade brain perfusion by means of direct cannulation of the right axillary artery, under moderate hypothermia in patients with acute type A aortic dissection.

METHODS

In, 25 consecutive patients (17 men) with a mean age of 62.6+/-14.8 years, aortic repair extended to the arch, for acute type A aortic dissection, was performed through a midline sternotomy. The right axillary artery was used for arterial systemic and brain perfusion at a rectal temperature of 25-27 degrees C.

RESULTS

Mean duration of CPB and aortic cross-clamping was 241+/-55 and 155+/-72 min, respectively. The mean duration of circulatory arrest of the lower body and brain perfusion was 39.7 (range, 24-55 min). All the patients survived the procedure and all but one were discharged from hospital. One patient had left arm paralysis which he recovered the first postoperative month. There were no other transient or permanent neurologic deficits. A CT scan was performed at discharge for routine postoperative evaluation. There were no local neurovascular complications related to the cannulation site except for one local re-exploration for bleeding.

CONCLUSIONS

The absence of any major permanent neurologic deficit or any visceral damages in our patients suggests that continuous moderate hypothermic cerebral perfusion, with an interval of circulatory arrest of the lower body, is adequate for acute type A aortic dissection surgery, allowing safe open repair of the distal aortic arch.

Combined Surgical and Endovascular Treatment of Aortic Type A Dissection

PURPOSE

We describe a combined approach for treatment of a type A aortic dissection with surgical repair of the ascending aorta and transluminal stenting of the descending aorta, therefore minimizing the consequences on the untreated aortic arch and descending aorta.

DESCRIPTION

From December 2002 to June 2003, 5 consecutive patients (4 men, 1 woman) suffering from type A aortic dissection were treated with resection of the ascending aorta or aortic hemi-arch. Before the open distal aortic anastomosis the Endofit endovascular graft (Endomed Inc, Phoenix, AZ), was deployed under direct vision distally to the origin of the left subclavian artery.

EVALUATION

Intraoperative stent graft placement was successful in all patients. There was no hospital mortality. Early results were satisfactory with a completely thrombosed false lumen in 2 patients and a partially thrombosed false lumen in 3 patients, 10 days after operation. Follow-up computed tomographic scan showed a completely thrombosed false lumen in 4 patients and a partially thrombosed false lumen in 1 patient.

CONCLUSIONS

This study shows that combined surgical and endovascular treatment of acute type A dissection is a feasible option, but further evaluation is necessary.

Repair of atrial septal defect through a limited right anterolateral thoracotomy in 242 patients: a cosmetic approach?

BACKGROUND

The repair of atrial septal defects (ASD) is often safely performed as a routine procedure in the young and asymptomatic patient. The purpose of this study is to evaluate the feasibility and especially the cosmetic result of this repair performed through a limited right anterolateral thoracotomy (RALT), with the complete cannulation and aortic cross-clamping conducted through the same incision.

METHODS

From January 1980 to June 2001 in our hospital, 242 patients (210 female) with atrial septal defects and a mean age of 26.2 +/- 12.0 years underwent operations through a RALT. Repaired defects included 235 ostium secundum defects and 7 sinus venosus defects with partial anomalous pulmonary venous connection (SV). Patients were contacted by phone to evaluate their satisfaction with the thoracic scar.

RESULTS

There was neither operative nor early mortality. All of the mentioned defects were successfully corrected. Mean bypass times were 12.37 +/- 4.9 minutes for ASD defects and 47.5 +/- 6.4 minutes for SV defects. The mean stay in the intensive care unit was 1.3 +/- 0.5 days. Most of the patients (86.3%) were fully satisfied with the cosmetic result.

CONCLUSIONS

The right anterolateral thoracotomy incision provides a safe and effective approach for the correction of the ASD. This approach can be safely performed without any new instruments and without peripheral incisions, provides good exposure for the surgeon to work comfortably, and achieves a cosmetically superior result in selected cases.

Dramatic post-cardiotomy outcome, due to severe anaphylactic reaction to protamine

Immunologic reactions to protamine sulfate during cardiac surgery are very rare. The frequency and outcome of such adverse reactions is unclear. We report a case of lethal anaphylactic reaction to protamine that occurred in a non-diabetic patient following the uneventful replacement of the ascending aorta. We also briefly review the mechanisms of this adverse reaction and emit some considerations on the management of this situation.

Influence of technique of coronary artery implantation on long-term results in composite aortic root replacement

BACKGROUND

Long-term results after composite graft aortic root replacement may depend on the insertion technique. The aim of this study is to assess the influence of the technique of coronary artery implantation on long-term results in composite aortic root replacement.

METHODS

One hundred fifty consecutive patients (mean age, 55 years; 119 men) with different disorders of the ascending aorta who underwent aortic root replacement with a composite graft prosthesis between January 1985 and December 1999 were retrospectively studied. Thirteen patients had previously undergone cardiovascular surgery. The open button technique was performed in 65 patients (43.3%, group 1) and the inclusion technique in 85 patients (56.7%, group 2). Mean follow-up was 70.5 months. Surgery was elective in 110 procedures (73%).

RESULTS

Global actuarial survival was 76.1% +/- 4.3% for group 1 and 73.7% +/- 3.9% for group 2 at 10 years (p = 0.22). Freedom from reoperation excluding early deaths was 81% +/- 3% for group 1 and 86% +/- 2.2% for group 2 at 10 years (p = 0.62). Group 2 demonstrated a statistically significantly higher occurrence of pseudoaneurysm formation versus group 1 (p = 0.04).

CONCLUSIONS

Composite graft aortic root replacement is a safe and effective therapy for proximal aortic aneurysm and dissection, resulting in good early and long-term results irrespective of the anastomotic technique. However, the open button technique seems to avoid late false aneurysm formation at the anastomotic sites.

Aortic valve replacement with the freestyle stentless bioprosthesis with respect to spacial orientation of patient coronary ostia

OBJECTIVE

This study evaluates our results for safety and efficacy of aortic valve replacement using the Freestyle bioprosthesis (Medtronic, Inc, Minneapolis, Minn) with a new modified subcoronary implantation technique. This technique takes into account the spacial orientation of the stentless bioprosthesis in the aortic root with respect to the patient's coronary ostia rather than the native commissures.

METHODS

Fifty-two consecutive patients with predominant aortic valve stenosis underwent aortic valve replacement with a Freestyle bioprosthesis by means of the described modified subcoronary technique over a 15-month period. Fifty of them were followed up by means of echocardiography at discharge, 6 months, and 1 year. There were 19 men and 31 women, with a mean age of 76 +/- 7 years (range, 58-87 years). Valve size ranged from 21 to 27 mm.

RESULTS

Patients with bicuspid aortic valves had a significantly larger angle between both coronary ostia than patients with tricuspid aortic valves (P =.0001). The peak and mean systolic gradients decreased significantly during the first postoperative year for each valve size (P </=.001), and the effective valve areas increased significantly during this time interval for each valve size (P </=.01). Only 13 patients had aortic insufficiency at discharge, which was trivial in 9 and mild in 4 patients. The prevalence of trivial aortic insufficiency decreased during the first postoperative year, and that of mild aortic insufficiency remained unchanged. The sinotubular junction diameter was significantly greater than that of the aortic anulus for each valve size before operation (P <.001). The sinotubular junction diameter decreased significantly after aortic valve replacement and remained unchanged during the first postoperative year for each valve size (P <.001).

CONCLUSIONS

Aortic valve replacement with the Freestyle bioprosthesis using the modified subcoronary technique, which takes into account the spacial orientation of the patient's coronary ostia, has hemodynamic results similar to those of other series with different subcoronary implantation techniques. This technique is reproducible, safe at the coronary ostial level, and effective in accommodating variability in angles between human coronary ostia, ranging from 130 degrees to 170 degrees. Moreover, the great preoperative discrepancies between aortic anulus and sinotubular junction diameters are corrected immediately after operation.

[High-risk PTCA assisted by the Hemopump 14F: the Geneva experience]

INTRODUCTION

The hemopump is a transvalvular, catheter-mounted, left ventricular assist device, intended for surgical placement via the femoral artery (hemopump 21 Fr. outer diameter). This device has demonstrated its ability to unload the left ventricle, leading to myocardial protection and haemodynamic stabilisation in patients with cardiogenic shock and those undergoing high-risk coronary angioplasty (PTCA). Since 1994, a new hemopump system (14 Fr. in external diameter, flow rates of 1.5-2.2 l/min) has been developed for percutaneous insertion. The aim of this study is to describe the immediate and mid-term results obtained during Hemopump 14 Fr. assisted high-risk PTCA.

PATIENTS

Between September, 1993 and July, 1996, 8 males and 5 female patients (mean age 68.5 +/- 8.6 years) underwent Hemopump 14 Fr. supported high-risk PTCA.

RESULTS

Mean duration of hemopump assistance was 108 +/- 62 min. Hemopump support on maximum speed led to an increase of cardiac index from 2.0 +/- 0.3 to 2.2 +/- 0.5 l/min (p = 0.04) and a decrease of pulmonary wedge pressure from 17 +/- 8 to 14 +/- 8 mm Hg (p = 0.004). LDH increased (463 +/- 305 to 558 +/- 237 u/l-p = 0.05) and the platelet count remained stable (192,840 +/- 60,904 to 190,230 +/- 56,492/mm3). Successful balloon angioplasty was performed in all patients. There was no hospital mortality. Three patients (23%) required blood transfusion. During follow-up, 1 patient (7.7%) developed femoral artery occlusion necessitating surgical repair, and 3 patients (23%) died from cardiac causes 3, 9 and 14 months after the procedure.

CONCLUSIONS

The 14 Fr. Hemopump device may constitute a useful percutaneous mode of haemodynamic support for patients undergoing high-risk PTCA. The haemolysis it causes is mild and not clinically significant, but the hemopump is associated with a significant rate of local vascular complications. Recent improvements in interventional techniques and hardware have decreased the necessity for circulatory assistance during elective PTCA, even for very ill patients. Nevertheless, indications such as cardiogenic shock, the "bridge" period prior to heart transplantation and video-assisted minimally invasive cardiac surgery, or haemodynamic support of the right ventricle are the new applications of the hemopump.

Aorta-cutaneous fistula as a rare complication of localized chronic mediastinitis

A 35-year-old man was admitted 5 years after congenital heart surgery complicated by Staphylococcus aureus and a cutaneous fistula located at the left fourth intercostal space. He was febrile (40 degrees C), suffering from sternal pain and suppuration from the old fistula. During examination arterial blood suddenly discharged from the fistula, so that surgery was immediately instituted. An infected Dacron tube implanting on the ascending aorta for a central aorto-pulmonary shunt was at the origin of a false aneurysm: this had led to the repeat formation of an aorta-cutaneous fistula and outbreak of external bleeding.

Left atrial myxoma presenting with myocardial infarction. Case report and review of the literature

Coronary artery embolization is an extremely rare and potentially lethal complication of atrial myxomas. We present a case report and a literature review of this clinical association. A 53-year-old woman presented with an acute infero-lateral myocardial infarction. Coronary angiography performed 1 h after the onset of pain disclosed an abrupt stop and multiple embolization of the peripheral right coronary artery (RCA). A transthoracic echocardiographic study revealed the presence in the left atrium of an echogenic, mobile mass, compatible with myxoma. The tumour was successfully removed surgically 2 weeks later and the patient is doing well one year post operatively.

Case report of a hypermobile pacemaker: abnormal manifestations and surgical correction

An abnormally mobile subclavian pacemaker pulse generator in a 49-year-old woman was stabilized by an absorbable mesh graft. This device was successfully replaced 2 years later without any problems. A 4-year follow-up evaluation was uneventful.

Successful management of a postinfarction left ventricular rupture using a sutureless technique with concomitant myocardial revascularization

We present a case of left ventricular (LV) rupture that occurred on the second day after inferolateral myocardial infarction (MI). An aggressive diagnostic approach with rapid coronary angiography prior to surgical repair provides a benefit characterized postoperatively by complete recovery of myocardial contractility in the akinetic infarcted area. We believe that coronary artery disease associated with subacute ventricular rupture may, in fact, be better investigated and simultaneously treated under a protocol of early surgical repair.

Blunt injury to the supra-aortic arteries

BACKGROUND

Blunt trauma causing injury to the vessels of the aortic arch is uncommon but may be attended by serious consequences. Most surgeons will experience only an occasional case and will need to rely on published literature for guidance.

METHODS

A Medline search over 1986-1995 was carried out using the following keywords: brachiocephalic trunk, common carotid artery and subclavian artery; injury was used as a subheading.

RESULTS AND CONCLUSION

After the aortic isthmus, the innominate is the most commonly injured artery in the chest. Whatever the site of an arterial lesion, however, angiography is the diagnostic test of choice. Some vascular lesions are relatively benign and may be managed without operation; this form of management may also be appropriate if there is severe associated neurological injury. Otherwise, operation using an approach and technique suited to the site of the injury is advocated.

Mitral valve repair in lupus valvulitis--report of a case and review of the literature

Valvulitis in systemic lupus erythematosus has been observed for many years. Fourteen cases of mitral valve replacement have been reported so far in the literature. In the light of all previously reported experiences, prosthetic valve related morbidity and mortality remain high in patients with systemic lupus erythematosus. We describe the first true instance of reconstructive approach in a patient who presented with severe mitral incompetence due to lupus valvulitis. The patient was clinically well with good valve function one year after surgery. Reconstructive mitral valve surgery may be preferable for the surgical management of mitral regurgitation in active lupus valvulitis since it eliminates the need for anticoagulation and avoids the disadvantages of different types of prostheses in these young patients who are under prolonged steroid therapy and have usually associated renal failure.

Multiple in vivo full-thickness myocardial biopsies by freeze-clamping

A technique was developed to permit multiple large biopsies of the in vivo myocardium to measure certain metabolites (ATP, CP, myocardial glycogen, lactate) with minimal chance of ventricular fibrillation or severe alterations in the heart's ability to maintain BP. Adult pigs with normal hearts (n = 9) as well as with hypertrophy (n = 5) created by aortic banding 3-4 months prior were anesthetized, intubated, and ventilated. After a sternotomy, the pericardium was opened and the epicardial surface was cleared of any adhesions. Biopsies were taken from the distal to proximal end of the heart. A suture (3-O Prolene) was placed in a figure-eight pattern in the area to be biopsied. A piece of the myocardium (50-100 mg) was grasped using a pair of narrow dressing forceps and frozen in liquid nitrogen. When the sample was completely frozen, a No. 11 scalpel blade, held at a 90 degrees angle to the epicardium throughout the cut, was used to carve out the full thickness biopsy. The sample was placed immediately in liquid nitrogen. The myocardial defect was repaired by using the previously placed suture buttressed with pieces of subcutaneous fat to prevent tearing the epicardial surface. This in vivo biopsy method has negligible complications and can be repeated or taught with constant reliability.