Use of an intraluminal shunt to repair a coronary bypass graft injury during resternotomy.
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Aged↗
Biomedical subjects
M Turina
Publications and source records attributed to M Turina.
Aneurysm of the superior mediastinal veins.
A case of true venous aneurysm with saccular dilation of the proximal half of the superior vena cava, the right innominate vein, and the distal two thirds of the left innominate vein in an 18-year-old white woman is presented. At surgery part of the aneurysmal wall was resected, and subsequently the mediastinal venous system was reconstructed with use of the rest of the aneurysmal wall. The postoperative course was uneventful. Operative treatment of mediastinal venous aneurysms is indicated to prevent possible major complications. We strongly suggest performance of this surgery only by means of a heart-lung machine.
Adolescent↗
The internal mammary artery malperfusion syndrome: incidence, treatment and angiographic verification.
Internal mammary artery (IMA) malperfusion syndrome is caused by an acute imbalance between myocardial demand and nutritional support through the mammary artery. In a consecutive series of 2326 isolated myocardial revascularizations-with at least one IMA to the left anterior descending branch (LAD) in 91.3% (2125/2326)-we identified 45 patients (1.9%) with a perioperative course suggesting IMA malperfusion syndrome. Additional saphenous vein graft to the distal segment of the LAD was performed during normothermic ventricular fibrillation in all patients. Hospital mortality was 4.4% (2/45), intra-aortic balloon pumping was required in 15.5% (7/45) and anterior myocardial infarction occurred in 28.8% (13/45). Coronary angiography was performed in all survivors between 3 and 24 months postoperatively. Wide patent IMA graft and patent saphenous vein graft were observed in 56% (24/43), narrowed but patent IMA graft and patent vein graft in 35% (15/43), while patent vein graft and not visualized IMA in 7% (3/43); in one patient with severely diseased peripheral LAD, no flow could be demonstrated in the IMA graft or in the additional vein graft (1/43, 2.4%). No major differences were found between early and late coronary angiography in these patients. Additional vein graft to distal LAD is the treatment of choice in acute IMA malperfusion syndrome. Despite patent vein graft with superior blood flow, early and late postoperative IMA flow to LAD is maintained in the majority of patients.
Adult↗
Outflow tract obstruction after mitral valve repair without an annuloplasty ring.
We report that systolic anterior motion of the mitral valve with significant left ventricular outflow tract obstruction can occur after mitral valve reconstruction without using an annuloplasty ring. A 69-year-old male patient with mitral regurgitation and ischemic heart disease underwent combined mitral valve reconstruction without an annuloplasty ring, and coronary artery bypass grafting. Intraoperative transesophageal echocardiography performed at the end of the operation revealed systolic anterior motion of the mitral valve with significant outflow tract obstruction requiring a second pump run with return to cardiopulmonary bypass and additional mitral valve replacement during the same thoracotomy.
Aged↗
Continuous versus bolus thermodilution cardiac output measurements--a comparative study.
OBJECTIVE: To compare the methods for continuous and bolus thermodilution cardiac output measurements. DESIGN: In vivo and in vitro experimental studies. SETTING: Surgical research division in a university hospital. SUBJECTS: Eight calves and flow bench model. INTERVENTIONS: Data were collected in vivo from eight calves instrumented with pulmonary artery catheters, which allowed both continuous and bolus thermodilution measurements. The pulmonary artery catheter was placed through the external jugular vein. All in vitro measurements were performed using a flow bench model. MEASUREMENTS AND MAIN RESULTS: A total of 232 bolus and continuous thermodilution measurements were analysed in vivo to determine the degree of agreement between the two methods. The absolute measurement bias was 0.14 L/min with 95% confidence limits ranging from -0.83 to 1.15 L/min. In vitro analysis of 576 measurements at six different temperature points (range 31 degrees to 41 degrees C), using clinically relevant flows (2 to 9 L/min), showed overestimation of flow values using continuous and bolus thermodilution methods. However, the continuous method showed better accuracy by a lower degree of overestimation. Systematic error was 9.7 +/- 8.4 (SD) % for continuous and 11.1 +/- 6.3% for the bolus method (p < .001). This effect was especially evident at lower flow rates. The influence of various temperatures on the accuracy and reproducibility of both methods of measurement was statistically significant but not clinically relevant. The infusion of lactated Ringer's lactate solution (infusion rates 100 to 1000 mL/hr) affects both methods at a low flow rate of 2 L/min, without causing a significant effect on continuous measurement at a higher flow rate (4 L/min). Shunting of 50% of circulating volume to the distal part of the thermal filament of the pulmonary catheter impaired the accuracy of continuous measurement without affecting results from bolus measurements (systematic error -26.8 +/- 8.2% for continuous and -5.2 +/- 4.1% for bolus thermodilution). CONCLUSIONS: Continuous thermodilution cardiac output measurement provided higher accuracy and greater resistance to thermal noise than standard bolus measurements. The correct placement of the catheter is essential for precise measurements.
Analysis of Variance↗
Development of nitrate tolerance in human arteries and veins: comparison of nitroglycerin and SPM 5185.
Nitrate tolerance is a clinical problem in patients with coronary artery disease and heart failure. Human internal mammary arteries and saphenous veins obtained intraoperatively were suspended in organ chambers, and isometric tension was measured. In the artery, nitroglycerin elicited a potent relaxation, which was significantly diminished after prolonged incubation with nitroglycerin (10(-6) M, 1 h). In contrast, no tolerance occurred in saphenous vein under the same conditions. However, incubation with 10(-5) M nitroglycerin also developed tolerance. Compared to nitroglycerin, the new cysteine-containing mononitrate SPM 5185 exhibited a lower sensitivity but comparable maximal relaxation in arteries and veins. In nitroglycerin-tolerant arteries and veins, SPM 5185 caused relaxations similar to those under control conditions. Our results show that in isolated blood vessels, vascular nitrate tolerance occurs more readily in the mammary artery than in the saphenous vein. SPM 5185 seems to be less prone to the development of tolerance, which may be advantageous during chronic nitrate therapy.
Acetylcysteine↗
Left ventricular chamber dilatation in hypertrophic cardiomyopathy: related variables and prognosis in patients with medical and surgical therapy.
BACKGROUND: To determine the incidence and prognosis of left ventricular dilatation and systolic dysfunction in 139 patients with hypertrophic cardiomyopathy during long term follow up. METHODS: Left ventricular chamber dilatation and systolic dysfunction (both together referred to as left ventricular chamber dilatation) were determined echocardiographically. Chamber dilatation was defined as an increase in the left ventricular end diastolic diameter of > 2% per year combined with a decrease in midventricular systolic fractional shortening of > 2% per year of follow up [10.3 (SD 6) years]. The predictive value for left ventricular chamber dilatation of clinical, invasive, and echocardiographic variables and its prognosis were assessed. RESULTS: In 119 of 139 individuals (86%), left ventricular chamber size and systolic function remained stable (group 1), and in 20/139 patients (14%) left ventricular chamber dilatation occurred during follow up (group 2). At baseline examination, symptoms such as dyspnoea and syncope occurred less often in group 1 than in group 2; New York Heart Association classification was lower in group 1 than in group 2 (P = 0.001). Left ventricular mass index relative to sex specific normal values was increased by 18% in group 1 and by 41% in group 2 (P = 0.04). Cumulative survival rates were slightly although not significantly higher in group 1 than in group 2. Event-free survival was significantly higher in group 1 than in group 2 (P < 0.05). CONCLUSIONS: (1) The development of left ventricular chamber dilatation and systolic dysfunction in hypertrophic cardiomyopathy occurs in approximately 1.5% of the patients per year. (2) Factors associated with left ventricular dilatation are dyspnoea, syncope, a higher functional classification, and a higher degree of left ventricular hypertrophy. (3) Patients with chamber dilatation have a worse prognosis than those without, particularly regarding quality of life.
Adolescent↗
Pseudoaneurysm following aortic homograft: clinical implications?
OBJECTIVE: To determine the prevalence of pseudoaneurysm formation after aortic (left ventricular outflow tract) homograft implantation and to evaluate predisposing factors. METHODS: Echocardiographic data were analysed in 30 patients for evidence of pseudoaneurysm formation after homograft implantation. Pseudoaneurysm was characterised as a perfused echo-free space between the homograft and the native aortic wall communicating with the left ventricular outflow tract. Clinical data were analysed for potential predisposing factors for pseudoaneurysm formation. RESULTS: Pseudoaneurysms were found in 22 of 30 patients. Mean age, length of follow up after surgery, aortic systolic pressure gradient (15 (SD 12) v 10 (4) mm Hg), aortic root diameter, and size of the homografts were comparable in patients with and without pseudoaneurysm. preoperative infection, operating techniques, and whether first or reoperation did not affect pseudoaneurysm formation. However, pseudoaneurysms were often localised at the site of an abscess or a paravalvular leak after eradicated prosthetic valve endocarditis. CONCLUSIONS: (1) Doppler echocardiography demonstrates that pseudoaneurysm formation is common after aortic homograft implantation. (2) A prospective study is needed to clarify the prognostic importance of pseudoaneurysms. (3) The high incidence of pseudoaneurysm formation may lead to an improvement of surgical technique (application of fibrin glue).
Adult↗
Low prime, heparin coated centrifugal pumps.
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Animals↗
[Experimental aortic aneurysm with endovascular technique].
We created a simple experimental aneurysm by a minimal operative trauma performing the balloon-dilatation and the rupture of the abdominal aorta of animals. The aorta of minipigs was dilated under angiographic control until the rupture became visible. The abdominal aorta and its branches were mapped out and measured. The angiographics were calculated using a planimetric device. The dilatation of the aorta was increased up to 3.5 times the initial diameter when rupture occurred. The microscopical examination showed lesions in all three layers of the vessel only at the rupture site and some focal lesions of the tunica intima. This one-step procedure of producing an experimental aneurysm is done using a low operative trauma and allows testing of endovascular systems using only one anaesthetic.
Aneurysm, Ruptured↗
Prediction of early cardiac morbidity and mortality following aorto-iliac reconstruction: comparison between clinical scoring systems, echocardiography and dipyridamole-thallium scanning.
Preoperative cardiac assessment may be difficult in patients with aorto-iliac and/or peripheral vascular disease because of severe physical limitation due to the disease itself, advanced age, locomotor problems or because of beta-blocker usage. 216 patients with aorto-iliac occlusive disease were studied; several cardiac risk scoring systems were determined for each patient. Preoperative echocardiography was performed in 182 patients and thallium-scanning in 63 patients. The results from the preoperative risk factor evaluations, echocardiographies and thallium examinations were correlated individually with the postoperative observed cardiac complications. Overall mortality was 2.8% (4 patients died from myocardial infarction). A total of 13 major postoperative cardiac events (10 myocardial infarctions and 3 life-threatening arrhythmias) were registered. No statistical correlation could be identified between the patient's clinical examination nor the scoring system and the occurrence of postoperative cardiac complications. 12 events occurred out of 13 patients who were shown to have a reversible defect on the preoperative thallium scan. These patients also presented hypokinesia or akinesia on the preoperative echocardiography. Thallium imaging and echocardiography represent a valid preoperative test to evaluate the risk of cardiac morbidity and mortality in vascular patients. Coronary angiography is recommended in patients suffering from progressive and/or unstable angina.
Aged↗
Left ventricular function and valvular reoperations.
Between 1961 and 1994, 1,120 adult and adolescent patients had reintervention on the aortic, mitral or both valves. Operative mortality was 7%; five, 10, 15 and 20 year survival rates were 81%, 65%, 54% and 52%, respectively. From the sixties to the nineties, the number of procedures (58 to 304), the age of patients (40 to 57 years), incidence of acute endocarditis (0 to 9%), concomitant coronary surgery (0 to 13%) and the number of repeated interventions (5% to 22%) gradually increased. Despite such increasingly difficult conditions the operative mortality remained low and five-year survival acceptable during the last 20 years. Operative mortality was significantly higher in patients over 65 years (11% vs. 5%), in cases with additional coronary surgery (16% vs. 5%) or interventions on the ascending aorta (17.5% vs. 5%). Left ventricular systolic function was quantitatively assessed before reoperation in 372 patients. In patients with stenotic mitral lesion or with aortic valvular lesion and additional surgical interventions reduced ejection fraction (< 50%) had no effect on late outcome. In regurgitant aortic and mitral lesions and interventions on both valves, there was a trend for less successful late outcome after reintervention, but the difference did not reach statistical significance. It is concluded that valvular reoperations can be performed nowadays with only slightly increased operative risk and an acceptable late outcome as compared to primary valvular operations. Hemodynamically significant valvular and/or prosthetic lesion should be corrected again without delay regardless of an impaired left ventricular function.
Adolescent↗
[True aneurysm of the ascending aorta in HIV disease].
A 31-year-old male who presented with a true aneurysm of the ascending aorta had for 5 years been seropositive for HIV-1 following intravenous drug abuse. Elective aneurysmectomy was refused. Controls by computerized tomography and echocardiography gave evidence of a progressive dilatation during the following 8 months. In February 1992 a further increase of the aneurysm with severe thoracic pain necessitated an emergency graft implantation. Histopathology of the resected aorta revealed a granulomatous giant cell mesaortitis. The postoperative course was uneventful and the patient remained free of cardiovascular symptoms, but died 25 months later due to multiple HIV-associated opportunistic infections. The differential diagnosis (Marfan's syndrome, vasculitis due to tuberculosis, syphilis and other infectious agents, rheumatological diseases, HIV-associated vasculitis) and the etiopathological considerations are discussed.
Adult↗
[Extra-anatomic thoraco-bifemoral bypass: an excellent alternative to in-situ reconstruction for repeat revascularization of the lower limbs].
Severe late complications after reconstruction of the abdominal aorta are unusual; when they occur, they demand a different strategy to treat the patient with success and to achieve a durably favourable long term outcome. These complications include prosthetic infection, enteric erosion and graft thrombosis. Treatment by resection of the infected graft and extra-anatomic reconstruction with axillary-femoral or axillary-popliteal bypass leaves the patient with an unreliable arterial inflow for the lower extremities. In patients who survived graft removal and extra-anatomic bypass, a source of major arterial inflow should be at least considered in order to secure a permanent repair. The descending thoracic aorta has been described as an ideal inflow source for definitive intracavitary conversion of extra-anatomic subcutaneous bypass and as a valid alternative to avoid dense adhesions in the abdomen or retroperitoneum. We present our experience with 8 patients in whom the aorta had been previously oversewn below the renal arteries (resection of infected graft [n = 4], repair of aorto-enteric fistula [n = 3]) or avoided because of dense adhesions after radiotherapy (n = 1). Temporary extra-anatomic reconstruction consists of an axillo-femoral (-popliteal) bypass on the right side with femoro-femoral cross-over graft. This method avoids surgery in the left thoraco-abdominal region, thus facilitating the definitive repair. Proper preoperative radiographic evaluation with inflow and outflow details is essential before conversion into thoraco-bifemoral bypass. Posterolateral thoracotomy is performed and the chest entered in the 7th interspace. The thoracic aorta is clamped tangentially and a bifurcated graft is anastomosed to the aorta. The bypass is passed through a retroperitoneal tunnel and anastomosed end-to-end with the distal portion of the previously inserted grafts; this technique avoids a second dissection of the vessel itself.(ABSTRACT TRUNCATED AT 250 WORDS)
Aorta, Abdominal↗
[Dynamic obstruction of the left ventricular outflow tract: surgical problems].
Dynamic subaortic obstruction caused by septal hypertrophy may worsen the hemodynamics in some patients after heart surgery. Resection of the hypertrophied septum allows normal left ventricular function. We describe two patients with subaortic stenosis and a complicated postoperative course following heart surgery and additional resection of the subaortic muscular stenosis. One patient was reoperated because of residual obstruction of the left ventricular outflow tract; the postoperative course was uneventful thereafter. The second patient died after the primary surgery because of low output syndrome and sepsis. The postoperative management of this group of patients is difficult, demanding frequent assessment of the patient's hemodynamic condition and echocardiographic surveillance.
Aged↗
[Ectopic ossification as a cause of vague abdominal pain following heart surgery: a case report].
Vague abdominal pain after cardiac surgery was caused by ectopic ossification in the distal part of sternotomy. The rarity of this complication (one case seen in recent years, operation volume: 1200 cases/year) prompted us to review the literature, where only 6 cases are described. Diagnostic problems and therapy are discussed.
Abdominal Pain↗
[Cardiovascular interventions in elderly patients].
From January 1981 to December 1990, 204 patients between 70 and 81 years of age underwent aortocoronary bypass-surgery, and 20 patients age 80 years or older underwent valvular surgery. The operative mortality rate (30-day mortality) of aortocoronary bypass-surgery was 6.8%; actuarial survival rate at 1 and 5 years was 92% and 86%, respectively. The operative mortality rate of valvular surgery was 15%; actuarial survival rate at 1 and 5 years was 78.5% and 67%, respectively. The mean follow-up was 25 months. Most patients undergoing myocardial revascularization (71%) and all the patients undergoing valvular surgery were preoperatively in New York Heart Association (NYHA) functional class III or IV, at the end of the follow-up in NYHA functional class I or II (95%). A rapid rise in the number of heart operations in the elderly is evident. It is associated with increased but acceptable operative risk. Longterm results and postoperative improvement of functional status are satisfactory.
Age Factors↗
[Problems and results of coronary reoperation].
Reoperative coronary bypass surgery has been encountered with increasing frequency over the last few years. It is associated with several major problems: difficulties with myocardial protection secondary to progression of arterial disease and occluded saphenous vein grafts, left ventricular dysfunction, and concomitant medical and vascular disease. We present our experience with 194 consecutive patients operated on between 1980 and 1992. They represent 4.0% of the overall number of isolated coronary revascularizations performed during the same period. There were 178 men and 16 women, mean age 58.6 +/- 7.4 years. The interval between primary coronary bypass grafting operation and redo-operation extended from 4 to 12 years, mean 8.2 years. At reoperation, 91.7% (178/194) of the patients received at least one arterial conduit, whereas revascularization with arterial conduits only was performed in 16 patients. Perioperative mortality amounted to 4.6% and was significantly higher than mortality of primary isolated coronary operations (1.6%) during the same period; the following significant morbidity was encountered: perioperative myocardial infarction (8.2%), postoperative low output requiring intraaortic counterpulsation (8.7%), postoperative bleeding (8.2%) and infectious complications (9.2%). First postoperative follow-up showed a significant improvement of symptomatology with a decrease of 1.5 point in NYHA functional class. Mid term survival is promising with a 5-year survival rate of 88.5%. Improved myocardial preservation and a trend towards complete revascularization should become routine and will probably reduce perioperative mortality and morbidity.
Adult↗