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PubMed2005

Surgical repair of post-infarction ventricular septal defect: 19 years of experience.

OBJECTIVES: To review our experience of surgical repair of post-infarction ventricular septal defect (VSD). METHODS: In the period 1983-2002, 50 patients underwent repair of VSD. Mean age was 66 years, male sex 52%. Infarct location was anterior in 60% and posterior in 40% of cases. Median interval between rupture and surgery was 2 days. Preoperative intra-aortic balloon counterpulsation was employed in 56%; a coronary angiogram was performed in 98% of cases. A patch repair technique was used in 90% of cases. Coronary bypass grafting was associated in 50% of patients. RESULTS: Mean aortic clamp time was 101+/-31 min. Global operative mortality was 36%, respectively 26.7% in anterior and 50% in posterior location (p=ns). Emergency operation and interval from rupture to surgery less than 3 days were univariate predictor of early mortality. Five years survival excluding operative deaths was 76%. CONCLUSIONS: The surgical repair of post-infarction VSD entails a high operative mortality; different techniques were employed with similar results. Emergency operation is associated with a worse short-term prognosis; long-term survival is acceptable.

Aged↗
PubMed2006

Performance of dynamic and isovolumetric trained skeletal muscle ventricles.

BACKGROUND: Dynamic training and maintaining muscle tension are important factors during skeletal muscle ventricle (SMV) conditioning that may improve SMV performance. This study sought to determine the effects of dynamic muscle training and progressive SMV resting pressure expansion on SMV pumping capability. MATERIALS AND METHODS: SMVs were constructed in 14 goats using the left latissimus dorsi muscle. SMVs were conditioned with a 40 ml constant-volume isovolumetric implant (n = 5, IsoVol group) or a compliant, pneumatic system that allowed dynamic shortening and direct exposure to resting pressures. Dynamic SMV resting pressure was either progressively increased from 40 to 100 to 120 mmHg (n = 5, HiP group) or maintained at 40 mmHg (n = 4, LowP group) during conditioning. After 8 to 10 weeks of electrical stimulation conditioning, SMVs were connected to a counterpulsation mock circulation system and SMV pumping performance evaluated across a range of pressures and stimulation parameters. RESULTS: SMV pumping performance was similar in each group. Stroke works generally increased with pressure and reached a plateau in all groups above 80 mmHg (120 msec contraction approximately 80 mJ/stroke; 480 msec contraction approximately 180 mJ/stroke). Stroke volumes decreased with pressure except at high stimulation levels where loading effects were observed. Chronic changes in SMV volume significantly effected pumping performance. CONCLUSIONS: These data suggest that acute pumping performance is not different between 8 to 10 weeks of dynamic or isovolumetric training if SMV volume is not constrained. A potentially improved SMV conditioning protocol is proposed that determines, positions, and maintains SMV volume near the initial volume for maximal isovolumetric pressure during conditioning.

Animals↗
PubMed2004

Composite arterial grafts versus conventional grafting for coronary artery bypass grafting.

OBJECTIVES: Composite arterial grafts for coronary artery bypass grafting surgery allow complete arterial revascularization but are limited by the inflow of a single internal thoracic artery supplying all the grafted vessels. We reviewed the safety of composite arterial grafts using either bilateral internal thoracic arteries or a single internal thoracic artery and radial artery. METHODS: From January 1999 to July 2002, 402 consecutive patients receiving composite grafts only were compared to a control group of patients (n = 542) undergoing coronary artery bypass grafting with internal thoracic artery and saphenous veins operated upon by the same surgeons. Two different statistical approaches were used to compare groups in this retrospective analysis. First, propensity score analysis with greedy matching technique was used to match patients from each group. Second, a multivariate analysis was performed looking at a combined patient outcome of death, intra-aortic balloon counterpulsation utilization, myocardial infarction, stroke, and prolonged ventilation on all patients in both groups. RESULTS: After matching by propensity score, the major clinical outcomes in composite arterial (n = 249) and control (n = 249) groups were found to be similar. The in-hospital mortality in the composite group was 1.2% as compared with 0.4% in matched patients (P =.62). However, patients in the composite group were found to have a significantly longer pump time (P <.0001), longer clamp time (P <.0001), increased incidence of prolonged mechanical ventilation (12.8% vs 4.8%; P =.002), and higher incidence of combined morbidity outcome (13.6% vs 6.4%; P =.007) as compared with matched patients. Multivariable analysis showed that composite arterial grafting was an independent predictor of the combined morbidity outcome with an odds ratio of 2.1 (1.2-3.7). CONCLUSIONS: These findings suggest that composite arterial grafting may be associated with an increase in risk-adjusted patient morbidity when compared with a conventional coronary artery bypass grafting group, although a mortality difference was not demonstrable.

Adult↗
PubMed2005

Reoperations after tricuspid valve repair.

OBJECTIVE: The objective was to analyze the short- and long-term results of patients with previous tricuspid valve repair who had valve dysfunction and required cardiac reoperations. METHODS: Between 1976 and 2002, 74 patients with a mean age of 53.8 +/- 12.2 years underwent valve reoperations for dysfunction of previous tricuspid valve repair. Mitral and tricuspid lesions were diagnosed in 40 patients (54%), triple valve disease (mitral, aortic, tricuspid) was diagnosed in 26 patients (35.1%), isolated tricuspid disease was diagnosed in 6 patients (8.1%), and aortic and tricuspid lesions were diagnosed in 2 patients (2.7%). Reoperations included tricuspid valve replacement in 43 patients (58.1%) and a new tricuspid valve repair procedure in the remaining 31 patients (41.9%). RESULTS: Hospital mortality (30-day or within first admission) was 35.1% (n = 26). In the multivariate analysis, risk factors for hospital mortality included body mass index less than 20 kg/m2 and greater than 24 kg/m2 , triple valve disease, use of intra-aortic balloon counterpulsation, and presence of postoperative complications. The follow-up was complete in 100% of patients, with a mean follow-up of 14.2 years (range 4 months to 26 years). The late mortality was 40.5% (n = 30). Predictors of late mortality were body mass index less than 20 kg/m2 , cardiac surgery before 1991, and development of dysfunction early after tricuspid valve repair. At the follow-up closing date, 19 patients are alive (25.7%). The actuarial survival was 11.8% +/- 4.9% at 26 years. CONCLUSIONS: Patients with failure of a tricuspid valve repair procedure requiring reoperation have a poor prognosis with a high mortality rate both in-hospital and in the long-term.

Adult↗
PubMed2005

Renal transplantation from non-heart-beating donors: a single-center 10-year experience.

BACKGROUND: Reluctance to accept non-heart-beating donors (NHBD) as a source of kidneys, is due to medical, ethical, and logistical reasons. Evidence suggest that the short-term graft survival is similar to that of kidneys obtained from heart-beating donors (HBD). However, few studies, with long-term follow-up are available. We conducted a single-center study of kidneys obtained from NHBD, in a 14-year period. METHODS: We studied 100 patients transplanted with kidneys between 1989 and 2004, using NHBD, supported by heart compression and mechanical ventilation (n = 24), intravascular in situ cooling (n = 59), or cardiorespiratory resuscitation plus manual abdominal counterpulsation without cooling (n = 17), the last technique being used from 1998. The median follow-up was 51 +/- 51 months (range, 1 to 170). The outcomes of these procedures were compared to those of 1025 transplantations of kidneys from HBD performed during the same period. RESULTS: The characteristics of the recipients did not differ significantly between the two groups. Kidneys from NHBD showed a significantly higher rate of delayed graft function (DGF; 84% vs 26%; (P < .001), furthermore, the primary nonfunction (PNF) incidence was significantly higher with NHBD vs HBD (16% vs 10%; P < .001). The incidence of acute rejection episodes (ARE) within 3 months and at 1 year did not differ between the groups of donors; however, more NHBD kidneys were lost from ARE. The short-term (3-month and 1 year) and long-term (5 and 10 years) renal function, determined by the serum creatinine levels, and patient and graft survival were not different for kidneys obtained from NHBD. CONCLUSIONS: The incidences of PNF and DGF were significantly higher with NHBD, which produced poorer renal function at the time of hospital discharge. One-, 5-, and 10-year graft survivals and renal function did not differ between NHBD and HBD grafts. In our series, PNF was the main barrier to the use of NHBD.

Adult↗
PubMed1976

Rupture of interventricular septum in acute myocardial infarction.

Three cases of rupture of the interventricular septum occurring coincident with acute inferior myocardial infarction are reported and the relevant literature is reviewed. One patient under-went successful surgical repair and, in addition, had an aneurysmectomy. Clues and pitfalls in diagnosis as well as the possible confusion with ruptured papillary muscle are discussed. Due to a dual blood supply to the interventricular septum, rupture occurs most often in the setting of advanced, diffuse coronary artery disease. Hypertension or other factors may be of lesser importance. Early surgical approach is advocated and may of necessity include infarctectomy, aneurysmectomy, and coronary artery by-pass surgery in addition ot repair of the ruptured interventricular septum. Use of an intraaortic balloon counterpulsator may prove to be of considerable help in the preoperative and postoperative management of these patients.

Aged↗
PubMed1976

Residual effects when chronic propranolol therapy is discontinued within 48 hours of cardiopulmonary bypass.

Recommendations regarding the safe waiting period between discontinuing chronic oral propranolol therapy and beginning cardiopulmonary bypass have varied from a few hours to 2 weeks. In the present study, utilizing adult dogs, propranolol was discontinued 8 or 48 hours prior to surgery. A reduction in cardiac output and elevations of left ventricular end-diastolic pressure, peak systolic pressure, and systemic resistance were noted when cardiac function was evaluated following the induction of anesthesia and prior to undertaking cardiopulmonary bypass. The magnitude of these differences was directly related to the degree of volume loading and inversely related to the interval between the last dose of propranol and the determination of cardiac function. Reduction of heart rate was the most evanescent of propranolol's hemodynamic effects as the marked bradycardia which persisted throughout the course of propranolol therapy was no longer evident 8 hours after the last oral dose of the drug. Following total cardiopulmonary bypass of 1 hour's duration, undertaken 8 hours after the last oral dose of propranolol, cardiac output and left ventricular end-diastolic pressure had returned to normal but peak systolic pressure and systemic resistance remained significantly elevated, When 48 hours had elapsed between discontinuing propranolol and beginning cardiopulmonary bypass, postbypass cardiac function was essentially normal with only slight persistent elevations of peak systolic pressure and systemic resistance detected. When the combined effects of ischemic heart disease and propranolol therapy, the altered metabolic and hemodynamic effects of different routes of drug administration, and the varying durations of cardiopulmonary bypass are taken into consideration, some of the discrepancies between previously reported clinical and experimental findings regarding the duration of persistent propranolol effects can be understood. The clinical course is usually benign in patients who have received propranolol to within a few hours of surgery without specific indication. However, it is often complicated when the drug is continued until just prior to surgery in patients dependant on propranolol for pain or arrhythmia control. In patients demonstrating propranolol dependence, control of symptoms with intra-aortic balloon counterpulsation is recommended followed by the gradual withdrawal of propranolol and elective aortocoronary bypass surgery.

Administration, Oral↗
PubMed2001

Predictive value of the Killip classification in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction.

The predictive value of Killip classification of acute myocardial infarction (AMI) in patients undergoing percutaneous coronary intervention (PCI) is not well established. We performed a pooled analysis of 2,654 patients with AMI enrolled in 3 primary angioplasty trials. Of these, 2,305 patients were class I, 302 were class II, and 47 were class III (class IV patients were excluded). Univariate and multivariate analyses were performed to determine if Killip class at admission was a predictor of in-hospital and 6-month mortality. Higher Killip classification was associated with greater in-hospital (2.4%, 7%, and 19% for class I, II, and III, respectively) and 6-month mortality (4%, 10%, and 28% for class I, II, and III, respectively). Higher Killip class was associated with increased age (p <0.001), history of diabetes (p <0.02), lower systolic blood pressure and higher heart rate at presentation (p <0.0001 for both), more 3-vessel disease (p <0.001), lower left ventricular ejection fraction (p <0.0001), and higher peak creatine phosphokinase (p <0.0001). With each increasing Killip class, there was an increased need for an intra-aortic balloon counterpulsation (p <0.001) and greater incidence of renal failure (p <0.001), major arrhythmia (p <0.001), and major bleeding (p <0.001). After controlling for potential confounding variables, Killip classification remained a multivariate predictor of mortality at both time end points. Killip classification at hospital admission remains a simple and useful independent predictor of in-hospital and 6-month mortality in patients with AMI who are undergoing primary PCI.

Aged↗
PubMed2000

The influence of gender on the outcome of coronary artery bypass surgery.

BACKGROUND: To assess the impact of gender as an independent risk factor for early and late morbidity and mortality following coronary artery bypass surgery. METHODS: Perioperative and long-term data on all 4,823 patients undergoing isolated coronary bypass operations from November 1989 to July 1998 were analyzed. Of these patients, 932 (19.3%) were females. RESULTS: During the years 1989 to 1998 there was a progressive increase in the percentage of women undergoing coronary artery bypass surgery. The following preoperative risk factors were more prevalent among women than men: age above 70, angina class 3 or 4, urgent operation, preoperative intraaortic balloon pump usage, congestive heart failure, previous percutaneous transluminal coronary angioplasty, diabetes, hypertension, and peripheral vascular disease (all p < 0.05). Men were more likely to have an ejection fraction less than 35%, three-vessel disease, repeat operations, and a recent history of smoking. Women had a statistically significant smaller mean body surface area than men (1.72+/-0.18 versus 1.96%+/-0.26% m2). On average, women had fewer bypass grafts constructed than men (2.9%+/-0.8% versus 3.2%+/-0.9%) and were less likely to have internal mammary artery grafting (76.2% versus 86.1%), multiple arterial conduits (10.1% versus 19.8%), or coronary endarterectomy performed (4.9% versus 8.6%). The early mortality rate in women was 2.7% versus 1.8% in men (p = 0.09). Women were more prone to perioperative myocardial infarction (4.5% versus 3.1% p < 0.05). After adjustment for other risk variables, female gender was not an independent predictor of early mortality but was a weak independent predictor for the prespecified composite endpoint of death, perioperative myocardial infarction, intraaortic balloon counterpulsation pump insertion, or stroke (8.55 versus 5.9%; odds ratio, 1.30; 95% confidence interval, 0.99 to 1.68; p = 0.05) Recurrent angina class 3 or 4 was more frequent in female patients (15.2%+/-4.0% versus 8.5%+/-2.0% at 60 months, p = 0.001) but not repeat revascularization procedures (percutaneous transluminal coronary angioplasty, redo) (0.6%+/-0.3% versus 4.1%+/-0.8% at 60 months). Actuarial survival at 60 months was greater in women then men (93.1%+/-1.7% versus 90.0%+/-1.0%), and after adjustment for other risk variables, female gender was protective for late survival (risk ratio, 0.40; 95% confidence interval, 0.16-0.74; p < 0.005). CONCLUSIONS: Perioperative complications were increased and recurrent angina more frequent in women. Despite this, late survival was increased in women compared with men after adjustment for other risk variables

Age Factors↗
PubMed2000

Ascending versus descending aortic balloon pumping: organ and myocardial perfusion during ischemia.

BACKGROUND: The ICS-Supracor (Abiomed, Danvers, MA) is a preshaped ascending aorta balloon pump. We compared the effects of this catheter with the classical descending intraaortic balloon pump (IABP). The study focused on hemodynamic effects, myocardial blood flow in normal and ischemic regions, cerebral perfusion, and peripheral organ perfusion. METHODS: We placed a stenosis on the lateral branch of the coronary artery to reduce flow 50% (sheep). Measurements included hemodynamic changes, myocardial blood flow, and organ flow (colored microspheres) at baseline, after stenosis, during IABP support, and during ICS support. RESULTS: Counterpulsation with the ICS led to a significantly higher peak diastolic aortic augmentation than with the IABP (IABP, 99 +/- 14 mm Hg; ICS, 140 +/- 29 mm Hg; p = 0.003). There was no significant change in cerebral perfusion or peripheral organ perfusion. Myocardial blood perfusion was significantly increased by the IABP as well as the ICS. This effect was seen in ischemic and nonischemic regions (subendocardial and subepicardial). The ICS improved myocardial blood flow significantly more than the IABP (IABP, 0.65 +/- 0.1 mL/min/g; ICS, 0.94 +/- 0.06 mL/min/g; p = 0.0005). CONCLUSIONS: The ICS increases myocardial blood flow in ischemic regions significantly more than the IABP, without impairment of cerebral flow. Assessment of vascular complications, peripherally and in the ascending aorta, has to await results of clinical trials.

Animals↗
PubMed2000

Intraaortic balloon pumping for predominantly right ventricular failure after heart transplantation.

BACKGROUND: Right ventricular failure from elevated pulmonary vascular resistance in the recipient is a main cause of early mortality after heart transplantation. When pharmacologic treatment is insufficient, mechanical circulatory assistance has been used to support the failing right ventricle. Considering right and left ventricular interdependence, we investigated whether intraaortic balloon counterpulsation (IABP) might also alleviate predominantly right ventricular dysfunction after heart transplantation. METHODS: Among 278 cardiac recipients, 12 adult patients underwent mechanical circulatory support for cardiac allograft dysfunction. Five patients were treated with percutaneous IABP for early postoperative low cardiac output syndrome characterized by predominantly right ventricular failure. Clinical data and hemodynamic variables were recorded before and during IABP treatment. RESULTS: Cardiac index (CI) and mean arterial pressure (MAP) increased (CI 1.7 +/- 0.1 to 2.5 +/- 0.2, MAP 53 +/- 12 to 71 +/- 7, p < 0.05) within 1 hour after IABP, whereas central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) decreased (CVP 21.6 +/- 1.7 to 13.8 +/- 3.1, p < .05; PAWP 14.8 +/- 4.9 to 12.4 +/- 3.7, nonsignificant). Within the next 12 hours, CI and mixed venous oxygen saturation increased (p < 0.05) and pulmonary artery pressure decreased (p < 0.05). All 5 patients were weaned successfully and 4 are long-term survivors with adequate cardiac performance at 1 year follow-up. CONCLUSIONS: Intraaortic balloon pumping is a minimally invasive circulatory assist device with proved efficiency in low cardiac output syndromes. This report shows that low output syndrome caused by predominantly right ventricular allograft failure may be an additional indication for IABP.

Adult↗
PubMed2001

Early and intensive continuous hemofiltration for severe renal failure after cardiac surgery.

BACKGROUND: The aim of this study was to test whether early and intensive use of continuous venovenous hemofiltration (CVVH) achieved a better than predicted outcome in patients with severe acute renal failure undergoing cardiac operations, and whether a simple and yet accurate model could be developed to predict their outcome before starting CVVH. METHODS: Medical record analysis with collection of demographic, clinical, and outcome information was used. RESULTS: Sixty-five consecutive patients were treated with early and intensive CVVH (mean operation to CVVH time, 2.38 days; pump-controlled ultrafiltration rate, 2 L/h) after coronary artery bypass grafting (56.9%), single valve procedure (16.9%), or combined operations (26.2%). In 32.3% of patients, intraaortic balloon counterpulsation was required and 20% of patients were emergencies. Sustained hypotension despite inotropic and vasopressor support occurred in 40% of patients and prolonged mechanical ventilation in 58.5%. Using an outcome prediction score specific for acute renal failure, the predicted risk of death was 66%. Actual mortality was 40% (p = 0.003). Using multivariate logistic regression analysis and neural network analysis, patient outcome could be predicted with good levels of accuracy (receiver operating characteristic 0.89 and 0.9, respectively). CONCLUSIONS: Early and aggressive CVVH is associated with better than predicted survival in severe acute renal failure after cardiac operations. Using readily available clinical data, the outcome of such patients can be predicted before the implementation of CVVH.

Acute Kidney Injury↗
PubMed2002

Anomalous origin of the left coronary artery from the pulmonary artery: results of surgical correction in five infants.

BACKGROUND: Five infants operated on for anomalous origin of the left coronary artery from the pulmonary artery were retrospectively analyzed. The mean age at operation was 12 +/- 6.7 weeks (95% confidence interval, 3.5 to 20 weeks), and mean weight at operation was 4.43 +/- 0.68 kg (95% confidence interval, 3.7 to 5.27 kg). All babies presented in infancy with left ventricular failure. Three had evidence of ischemia with left ventricular strain, and two had Q waves in anterolateral leads on electrocardiograph. Cross-sectional echocardiography showed dilated left ventricles with poor contractility in all babies with fractional shortening of 15.8% +/- 4.02% (95% confidence interval, 12% to 20%); moderate mitral regurgitation was seen in all babies. METHODS: All babies underwent operation as soon as the diagnosis was made. Four babies had direct reimplantation of left coronary artery into the aorta, and 1 had tunnel repair. Intraaortic balloon counterpulsation was used in 1 baby for hemodynamic instability and as prophylaxis in the remaining 4 babies postoperatively for 115 +/- 26.2 hours (95% confidence interval, 72 to 144 hours). RESULTS: All babies had delayed closure of the chest. There was no operative mortality. One baby was reoperated on for tunnel stenosis as well as pulmonary stenosis 4 months after primary repair. All babies were followed for 192 patient-months and show an improved fractional shortening. CONCLUSIONS: Early operation, early institution of intraaortic balloon counter pulsation for left ventricular support, and delayed sternal closure are the key to good results.

Coronary Vessel Anomalies↗
PubMed2002

Surgical coronary revascularization and antiarrhythmic therapy in survivors of out-of-hospital cardiac arrest.

BACKGROUND: Patients who survive out-of-hospital cardiac arrest are at high risk for recurrent arrest. Coronary artery bypass grafting (CABG) confers a survival advantage, but it is unclear whether antiarrhythmic drugs or an implanted defibrillator confer added benefit. This study was designed to determine predictors for further treatment, survival, and therapeutic internal cardiac defibrillator (ICD) discharge in this patient population. METHODS: One hundred and eight patients undergoing CABG after out-of-hospital cardiac arrest were identified over a 12-year period. Case records were retrospectively reviewed. Follow-up was obtained and predictors of outcome events were analyzed. RESULTS: Fifty-four (50%) patients underwent CABG only. Fifty-four received additional treatment that included ICD placement in 23 (21%), antiarrhythmic medications in 19 (18%), or both in 12 (11%). Predictors of ICD placement included left ventricular ejection fraction (LVEF) less than 40% and perioperative intraaortic balloon counterpulsation. ICD or medical management increased survival in patients with LVEF <40%. Predictors of increased mortality included age >65 years, Cleveland Severity Score >8, and female gender. Predictors of therapeutic ICD discharge included age >65 years, reoperative CABG, LVEF <40%, and positive postoperative electrophysiological (EP) study. No patient with a negative postoperative EP study received an ICD, and none suffered sudden cardiac death during follow-up. CONCLUSIONS: Patients with coronary artery disease anatomically suitable for CABG who survive an acute out-of-hospital cardiac arrest should undergo EP testing after CABG. Approximately half of these patients are adequately treated by CABG alone. The remainder may benefit from ICD placement or medical antiarrhythmic management.

Adult↗
PubMed2003

Myocardial revascularization for acute myocardial infarction: benefits and drawbacks of avoiding cardiopulmonary bypass.

BACKGROUND: Coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) is associated with increased mortality compared with CABG in non-AMI patients. Operating without cardiopulmonary bypass (CPB) might reduce this mortality. METHODS: Between January 1992 and December 1998, 225 patients underwent CABG within 7 days of AMI, 119 with CPB and 106 without. The two groups were similar regarding age, gender, left ventricular dysfunction, and incidence of cardiogenic shock. Mean number of grafts per patient was 3.1 in the CPB group, and 1.7 in the no-CPB group (p < 0.0001). RESULTS: Operative mortality in the CPB group was 12% compared with 3.8% without CPB (p = 0.027). Independent predictors of operative mortality were preoperative use of intraaortic balloon counterpulsation (IABP), nonuse of internal thoracic artery (ITA) to the left anerior descending artery, and the use of less than three grafts. Mortality of patients operated on with CPB within 48 hours of AMI was significantly higher (16.5% vs 4.3%, respectively; p = 0.044). However, patients operated on after 48 hours had similar mortality (5.8% vs 3.4%, respectively). Follow-up ranged from 6 to 84 months. Five-year survival (Kaplan-Meier) of both groups was similar (81%). Patients operated on with CPB had similar rates of recurrent angina; however, they had lower prevalence of reinterventions (0.8% vs 6.3%; p = 0.03). CONCLUSIONS: Our study suggests that CPB can be used safely for most patients referred for CABG within the first week of AMI. However, for emergency patients operated on within the first 48 hours of symptom onset, we advocate avoiding CPB because it is associated with lower operative mortality.

Aged↗
PubMed2004

Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock.

BACKGROUND: Postcardiotomy cardiogenic shock occurs in approximately 1% of patients. We prospectively evaluated the early and long-term outcome as well as predictors of survival when using temporary extracorporeal membrane oxygenation (ECMO) support. METHODS: During 5 years 219 of 18150 patients (1.2%) undergoing cardiac surgery (coronary artery bypass grafting, n = 119; aortic valve replacement, n = 24; coronary artery bypass grafting and aortic valve replacement, n = 21; coronary artery bypass grafting and mitral valve replacement, n = 11; other procedures, n = 44) required temporary postoperative ECMO support. The ECMO implantation was performed through the femoral vessels or through the right atrium and ascending aorta. Additional intraaortic balloon counterpulsation was employed in 144 patients to improve coronary blood flow. RESULTS: Mean duration of ECMO support was 2.8 +/- 2.2 days. One hundred thirty-four patients (60%) were successfully weaned from ECMO. Of these, 52 patients (24%) were discharged from the hospital after 29.9 +/- 24 days. The main cause of death was myocardial failure. Five-year follow-up is 96% complete; 37 patients (74%) were alive with reasonable exercise capacity. CONCLUSIONS: Extracorporeal membrane oxygenation is an acceptable technique for short-term treatment of refractory postoperative low cardiac output. It can save the lives of a group of very high risk patients.

Aged↗
PubMed1985

Complications of ascending aortic intraaortic balloon pump cannulation.

Choice of a route of cannulation for intraaortic balloon counterpulsation during cardiopulmonary bypass is related to accessibility. In those patients in whom it is impossible to pass the intraaortic balloon pump (IABP) into the common femoral artery, ascending aortic cannulation is a rapid and direct method of insertion. Eight patients are described in whom ascending aortic IABP cannulation was undertaken to enable weaning from cardiopulmonary bypass after cardiac surgical procedures. The following problems were encountered: graft infection, aberrant cannulation of the left subclavian artery, left coronary artery embolism, and inability to close the sternum due to mechanical tamponade. A technique is described for insertion of the IABP using a polytetrafluoroethylene (Impra) graft and closed-chest decannulation. Although considerable morbidity and mortality are associated with ascending aortic cannulation, it is simple, fast, and effective, and should be considered for all patients requiring postoperative IABP support in whom peripheral vascular disease makes access difficult.

Aged↗
PubMed1982

Circulatory assistance with a cardiac allograft after exclusion of the canine left ventricle.

Cardiogenic shock after myocardial infarction still carries a high mortality despite use of intraaortic counterpulsation and early surgical revascularization. An experimental canine model of left ventricular exclusion and circulation support was developed by closing the mitral valve and by interposing "in series" a cardiac allograft between pulmonary and systemic circulations. This preparation was able to support the recipient circulation after cardiopulmonary bypass in 25 animals. In 16 dogs the graft sustained life for from 1 to 32 days. It is hypothesized that such left ventricular assistance could be used to maintain the life of patients in cardiogenic shock after myocardial infarction. By providing maximal left ventricular decompression and improvement of the native coronary perfusion, this method may reverse the metabolic imbalance responsible for extension of the infarction, thereby salvaging muscle that is in jeopardy but still viable.

Animals↗