In adult congenital patients with transposition of the great arteries originally treated with the Mustard (atrial switch) procedure, the most common reason for re‐intervention is baffle stenosis. This may be exacerbated by permanent transvenous pacemaker lead placement across the baffle.

HomeCirculationVol. 130, No. 15Epicardial Coronary Artery Compression Secondary to Pericardial Adhesions Demonstrated by Multi-Modality Imaging, and Treated by Coronary Stenting Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBEpicardial Coronary Artery Compression Secondary to Pericardial Adhesions Demonstrated by Multi-Modality Imaging, and Treated by Coronary Stenting David H. Hsi, MD, Lynn B. McGrath, MD, Judd Salamat, DO, Mitchell Simon, MD and Jon C. George, MD David H. HsiDavid H. Hsi From the Departments of Cardiology (D.H.H., J.S., J.C.G.) and Cardiac Surgery (L.B.M.), Deborah Heart and Lung Hospital, Browns Mills, NJ; and Robert Wood Johnson University Hospital, Department of Radiology New Brunswick, NJ (M.S.). Search for more papers by this author , Lynn B. McGrathLynn B. McGrath From the Departments of Cardiology (D.H.H., J.S., J.C.G.) and Cardiac Surgery (L.B.M.), Deborah Heart and Lung Hospital, Browns Mills, NJ; and Robert Wood Johnson University Hospital, Department of Radiology New Brunswick, NJ (M.S.). Search for more papers by this author , Judd SalamatJudd Salamat From the Departments of Cardiology (D.H.H., J.S., J.C.G.) and Cardiac Surgery (L.B.M.), Deborah Heart and Lung Hospital, Browns Mills, NJ; and Robert Wood Johnson University Hospital, Department of Radiology New Brunswick, NJ (M.S.). Search for more papers by this author , Mitchell SimonMitchell Simon From the Departments of Cardiology (D.H.H., J.S., J.C.G.) and Cardiac Surgery (L.B.M.), Deborah Heart and Lung Hospital, Browns Mills, NJ; and Robert Wood Johnson University Hospital, Department of Radiology New Brunswick, NJ (M.S.). Search for more papers by this author and Jon C. GeorgeJon C. George From the Departments of Cardiology (D.H.H., J.S., J.C.G.) and Cardiac Surgery (L.B.M.), Deborah Heart and Lung Hospital, Browns Mills, NJ; and Robert Wood Johnson University Hospital, Department of Radiology New Brunswick, NJ (M.S.). Search for more papers by this author Originally published7 Oct 2014https://doi.org/10.1161/CIRCULATIONAHA.114.011068Circulation. 2014;130:e129–e130A 42-year-old female presented with sudden onset severe left-sided chest pain radiating to the left arm while watching a movie at home. She was rushed to the hospital within 10 minutes. She was found having ST elevation myocardial infarction on ECG and ventricular fibrillation arrest 2 times requiring cardiac resuscitation and defibrillation. Retrospectively, the patient recalled some ill-defined episodes of chest pain with exercise in the past few months before the admission. Her past surgical history 20 years previous was significant for video-assisted thoracoscopic surgery and pericardial window for removal of large, nonhemorrhagic pericardial effusion of 1.2 L, which occurred ≈1 week after her chest wall injury from basketball. Bedside transthoracic echocardiography revealed mildly decreased left ventricular systolic ejection fraction of 40% to 45%, and pericardial thickening with small pericardial effusion. The patient underwent emergent cardiac catheterization and coronary angiography, which demonstrated linear filling defects involving multiple coronary segments (Figure 1) including the diagonal, obtuse marginal, and ramus branches, suggestive of extrinsic band-like compression of the coronaries. Cardiac MRI with gadolinium contrast demonstrated regional, thick enhancing fibrous scar tethering the pericardium to the lateral walls, with corresponding akinesis (Figure 2, Movie I in the online-only Data Supplement). But the chest x-ray, fluroroscopy, and computer tomography did not show any obvious pericardial calcification. Serial enzyme assays confirmed creatine kinase-MB peaked at 11.8 ng/mL, and troponin I 8.1 ng/mL. After extensive review of patient’s clinical presentation, initial coronary angiography images and noninvasive cardiac imaging, it was predominantly felt that she likely had a horizontal fibrous band compressing the coronary segments and causing acute ischemia, injury, and electric instability. The patient was brought back to the cardiac catheterization laboratory for percutaneous intervention. Intracoronary optical coherence tomography imaging confirmed discrete dynamic extrinsic compression of the coronary artery (Figure 3). Multivessel stenting was performed using drug-eluting stents to the ramus, obtuse marginal, and diagonal branches (Figure 4). Final optical coherence tomography imaging confirmed excellent stent expansion and apposition (Figure 5). Serology was positive for antibodies to Coxsackie virus B1, B2, B3, B4, B5, and B6 elevated with titers up to 1:32 (normal <1:8). A single chamber cardiac defibrillator was implanted for secondary prevention of sudden cardiac death before discharge. Our patient had a rare occurrence of external coronary systolic compression not involving the left anterior descending coronary artery, documented by multi-modality imaging of echocardiography, cardiac MRI, coronary angiography, and optical coherence tomography. This presentation is not consistent with primary myocardial bridging, which involves left anterior descending artery in 93% of patients.1 Clinically, she had acute ST segment elevation myocardial infarction without coronary atherosclerosis or coronary dissection. From her previous history of chest wall trauma, large pericardial effusion, pericardiotomy, and video-assisted thoracoscopic surgery, the patient most likely had fibrous tissue adhesion and progressive coronary compression over the course of many years. Acute chest trauma secondary to car accidents has been reported to cause acute coronary thrombosis.2 Some authors have reported other causes of epicardial coronary compression attributable to fibrosing mediastinitis.3 Our patient did not have any obvious recent trauma or new pericardial effusion. However, she had diffusely abnormal serology results indicating Coxsackie B virus infection and possibly subacute pericarditis causing worsening coronary compression and ischemia. Weiss and colleagues4 reported 2 cases of diastolic coronary compression attributable to postoperative pericardial calcification 10 to 20 years after the initial surgery. These 2 patients were treated with coronary stenting with good results. Based on our review, this is the first reported case of coronary artery compression involving multiple branches demonstrated by multi-modality imaging, and successfully treated by coronary stenting in the setting of acute myocardial infarction.Download figureDownload PowerPointFigure 1. Coronary angiography demonstrating filling defects (arrowheads) in a linear fashion along the lateral epicardial coronary branches.Download figureDownload PowerPointFigure 2. Cardiac MRI demonstrating a thick enhancing fibrous pericardium (arrowheads).Download figureDownload PowerPointFigure 3. Optical coherence tomography imaging confirming extrinsic compression of the coronary artery (asterisks).Download figureDownload PowerPointFigure 4. Final angiographic image demonstrating successful treatment of coronary compression with multivessel stenting (arrowheads).Download figureDownload PowerPointFigure 5. Final optical coherence tomography imaging confirming adequate stent expansion of coronary lumen at previous site of extrinsic compression.AcknowledgmentsWe thank Barbara Minnick for her expert assistance in image preparation.DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.114.011068/-/DC1.Correspondence to David H. Hsi, MD, FACC, FASE, Deborah Heart and Lung Hospital, 200 Trenton Road, Browns Mills, NJ 08015. E-mail [email protected]References1. Mookadam F, Green J, Holmes D, Moustafa SE, Rihal C. Clinical relevance of myocardial bridging severity: single center experience.Eur J Clin Invest. 2009; 39:110–115.CrossrefMedlineGoogle Scholar2. Mastroroberto P, Di Mizio G, Colosimo F, Ricci P. Occlusion of left and right coronary arteries and coronary sinus following blunt chest trauma.J Forensic Sci. 2011; 56:1349–1351.CrossrefMedlineGoogle Scholar3. Posligua W, Zarrin-Khameh N, Tsai P, Lakkis N. Fibrosing mediastinitis causing ostial coronary artery compression in a young woman.J Am Coll Cardiol. 2012; 60:2693.CrossrefMedlineGoogle Scholar4. Weiss SA, Anderson AS, Raman J, Jolly N. Postoperative pericardial calcification causing diastolic coronary compression.Ann Thorac Surg. 2010; 90:1001–1004.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Schaikewitz M, Nnaoma C, Meredith R, Uretsky S, Blitz L, Klein A and Rosenthal M (2020) Acute Myocardial Infarction With Cardiogenic Shock Due to Pericardial Constriction and Multivessel Coronary Obstruction, JACC: Case Reports, 10.1016/j.jaccas.2020.05.031, 2:11, (1708-1712), Online publication date: 1-Sep-2020. October 7, 2014Vol 130, Issue 15 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.114.011068PMID: 25287772 Originally publishedOctober 7, 2014 PDF download Advertisement SubjectsComputerized Tomography (CT)ImagingStent

Myocardial malondialdehyde concentration (MDA) as an index of membrane lipoperoxidation was measured in previously ischemic isolated rabbit hearts reperfused with Krebs solution equilibrated with different oxygen concentrations. Hearts were subjected to a ischemic period of 30 min at 4 degrees C and then reperfused at 37 degrees C with a Krebs-Henseleit solution equilibrated with 95% oxygen (group 1), 65% oxygen (group 2), or 21% oxygen (group 3). MDA concentration in nanomoles per gram protein (mean +/- SEM) at the end of reperfusion in group 1 (n = 5) was 357 +/- 18; in group 2 (n = 5) 282 +/- 18; and in group 3 (n = 5) 246 +/- 16 (p =.0008, group 1 vs. group 3; p =.0109, group 1 vs. group 2). The results support that oxidative stress after ischemia and reperfusion is modulated by the oxygen concentration of the reperfusate in the crystalloid-perfused isolated rabbit heart such that higher oxygen concentrations are associated with greater oxidative stress.

A 69-year-old male cigarette smoker with bullous emphysema presented with progressive dyspnea, chest pain, and hemoptysis. Chest radiograph revealed 100% right-sided pneumothorax. A 28 F chest tube was inserted through the fifth intercostal space in the anterior axillary line. The chest tube was removed in 36 hours. The following day, the patient had an episode of coughing, which resulted in sudden protrusion of a 9-cm bulla through the chest tube site (Fig 1). The patient remained comfortable and afebrile. Computed tomography of the chest confirmed severe bullous disease, herniated bulla, and compression atelectasis in lower lung fields (Fig 2). The patient underwent emergency bullectomy through antero-lateral thoracotomy. Surgical findings revealed the eviscerated bulla to be a part of the right lower lobe. The patient was discharged home on the ninth postoperative day.Figure 2View Large Image Figure ViewerDownload (PPT)

An important indicator for the long-term recovery after valve replacement surgery is postoperative valve gradient. This information is available only for patients received catheterization or echocardiogram postoperatively. It is plausible that sicker patients are more inclined to undergo these postoperative procedures and their valve gradients tend to be higher. Under this situation, ignoring the missing values and using sample mean based on the available information as an estimate of the whole study population leads to overestimation. Regression estimator is a reasonable choice to eliminate this bias if independent (explanatory) variables closely associated with both residual valve gradient and nonresponse mechanism can be identified. Using a series of patients receiving St. Jude Medical prosthetic valves, we found that valve area index can be used as an independent variable in the regression estimator. Two digressions from the standard assumptions used in linear regression, heteroscedastic trend of the error term and outliers were found in the data set. Iteratively reweighted least square (IRLS) was adopted to handle heteroscedasticity. Influence function approach was used to evaluate the sensitivity of outliers in regression estimator. Under an equal response rate mechanism, IRLS not only solves the problem of heteroscedasticity, but is also less sensitive to outliers.

We studied myocardial Ca2+ cycling during cardiopulmonary bypass and cold-blood cardioplegia (CPB/CBC) in patients with coronary heart disease undergoing coronary artery bypass grafting. Right atrial biopsies were taken from 13 patients before and after CPB/CBC: after pericardiotomy, immediately after aortic cross-clamp removal, and following termination of CPB/CBC. Changes in ionized Ca2+ concentration (nM) were monitored with indo 1 during Ca2+ uptake and Ca2+ release by sarcoplasmic reticulum in a medium containing 1% homogenized myocardium. Ryanodine inhibition was used to estimate Ca2+ release channel activity. With CPB/CBC, the initial Ca2+ concentration of reaction media increased 33%, (962 +/- 150 to 1262 +/- 106 nM; mean +/- SD). Ca2+ cycling increased asymmetrically, 108% for Ca2+ uptake (3.91 +/- 1.32 to 8.15 +/- 3.17 nM/s), 197% for Ca2+ release (0.90 +/- 0.80 to 2.73 +/- 1.13 nM/s), and 68% for the ratio of Ca(2+)-release to Ca(2+)-uptake activities (0.22 +/- 0.14 to 0.37 +/- 0.13). The dissociation constant of the Ca2+ pump for Ca2+ was unaltered by CPB/CBC (289 +/- 76 nM). During the time period that was studied post-bypass, Ca(2+)-pump activity remained increased, although the Ca(2+)-channel activity returned to pre-bypass values (all p < 0.05). We conclude that CPB/CBC produces increased myocardial Ca2+ load, twofold increased Ca2+ uptake, and threefold increased Ca2+ release by sarcoplasmic reticulum.

From 1983 to 1992, 203 patients with chronic congestive heart failure and no angina underwent primary coronary artery bypass. This represented 3% of patients undergoing coronary artery bypass grafting. Ninety-two percent of the patients were in New York Heart Association (NYHA) functional class III or IV prior to undergoing coronary artery bypass grafting. Thallium perfusion imaging was performed in 21% of the patients, with a reversible defect present in 88%. An internal mammary artery graft was used in 70% of the patients. The hospital mortality was 6.0% and the actuarial survival at 5 years was 59%. An improvement in NYHA functional class occurred in 75% of the surviving patients with a mean improvement of 1.6 +/- 0.6 functional classes. Univariate analysis identified risk factors for hospital death as emergency operation, recent myocardial infarction (< 30 days), and the need for an intra-aortic balloon pump. A trend emerged for nonuse of an internal mammary artery to predict hospital death. A positive thallium perfusion scan was not a predictor of early or late survival, nor did it influence NYHA functional class. The use of the internal mammary artery significantly enhanced late survival (p = 0.01), however, did not affect the functional class of survivors. We conclude that coronary artery bypass grafting is effective in ameliorating symptoms of chronic congestive heart failure in patients suffering from chronic ischemic cardiomyopathy and can be performed with acceptable early and late mortality.

Reconstruction techniques for major vessels and intracardiac defect repair use synthetic grafts or autogenic pericardium. Here, autologous abdominal parietal peritoneum with the overlying posterior rectus sheath as a biologic membrane are evaluated. Twelve adult canines were used. Via a midline subumbilical incision, the parietal peritoneum and overlying posterior rectus sheath were harvested. In the first group of six, the membrane was used to repair the right ventricular infundibulum and perform pulmonary artery annuloplasty. In the second group of six, under cardiopulmonary bypass and moderate hypothermia, the right atrium was opened and a secundum type defect was created. Autopsies performed 90 days after surgery revealed mild intrapericardial adhesions and moderate pericardial reaction over the cardiotomy incisions. The right ventricular outflow tract patch was nonaneurysmal. The interatrial patch was intact without thrombi. Histologic examination revealed intact membrane morphology, fibroblasts, smooth muscle cells, and endothelialization. Proline C14 uptake and autoradiography detected cellular viability of implanted membranes. These findings suggest that the peritoneum with overlying sheath repaired vascular and intracardiac defects and substituted for pericardium. Future studies are needed before clinical use.

BACKGROUND:Previous studies indicate that a minimal prosthetic valve area index (VAI) of > or = 0.9 cm2/m2 for aortic and > or = 1.3 cm2/m2 for mitral valves minimizes postoperative pressure gradients.METHODS AND RESULTS:To determine VAI as an independent risk factor for postoperative events, 607 isolated aortic valve replacement (AVR) and 482 isolated mitral valve replacement (MVR) operations with the St Jude Medical valve were studied. End points included hospital deaths, NYHA functional class, late death and late valve-related death, major thromboembolism, anticoagulant-related hemorrhage, and reoperation. VAI was calculated from the ratio of prosthetic valve area to body surface area for each patient, and a range and mean were obtained for each valve size. Follow-up ranged from 1 to 120 months, totaled 2964 patient-years, and was 98% complete. Mean and range of VAI (cm2/m2) were 1.31 (0.74 to 2.86) in the aortic and 2.5 (1.4 to 6.32) in the mitral group. There were 33 AVR (5.4%) and 38 MVR (7.9%) hospital deaths. VAI was not a risk factor for NYHA class, early death, late death, or other postoperative events. The actuarial survival rates, 84% for AVR and 80% for MVR at 5 years, were not affected by VAI.CONCLUSIONS:Within the ranges measured, VAI did not influence the end points of the study.

Despite recent advances in techniques of reperfusion for acute myocardial ischemia, myocardial salvage remains suboptimal. beta-Blockers have been shown to limit infarct size during acute ischemia, but their negative inotropic properties have limited their use. Cardiopulmonary bypass is an attractive technique for cardiac resuscitation because it can stabilize a hemodynamically compromised patient and potentially reduce myocardial oxygen consumption. In an attempt to maximize myocardial salvage in the setting of acute ischemia, the combination of esmolol, an ultrashort-acting beta-blocker, with percutaneous cardiopulmonary bypass was evaluated. Four groups of instrumented dogs underwent 2 hours of myocardial ischemia induced by occlusion of the proximal left anterior descending coronary artery, followed by 1 hour of reperfusion. Throughout the period of ischemia and reperfusion, esmolol plus percutaneous cardiopulmonary bypass was compared with esmolol alone, percutaneous cardiopulmonary bypass alone, and control conditions. After the reperfusion period, the extent of infarction of the left ventricle at risk was determined. Four animals had intractable arrhythmias: one in the esmolol plus bypass group, one in the esmolol group, and two in the control group. The extent of infarction of the left ventricle at risk was significantly reduced in the esmolol plus bypass group (30%) compared with bypass alone (52%), with esmolol alone (54%), and with the control groups (59%; p < 0.05). We conclude that in this experimental model the combination of esmolol with bypass improves myocardial salvage after ischemia and reperfusion.

The internal thoracic artery (ITA) is the conduit of choice for coronary artery bypass grafting (CABG). This study, utilizing a canine model, evaluates cryopreserved ITA. Sixteen ITAs were harvested and cryopreserved according to United CryoInstitute protocol. Test conduits, 5 cm long and 4 mm mean diameter, were anastomosed to the ligated carotid artery of an unmatched mongrel recipient, above and below the site of native artery ligation. Graft patency was assessed by angiography at 14 days (early) and 980 days (late) postoperatively. Catheterization of the 16 vessels identified three (18%) early and one (6%) late graft occlusion. Ninety days postoperatively, each dog was killed and the graft harvested for histopathological and functional evaluation. Morphologic evaluation, using conventional staining, showed preserved cellular structure, decrease in smooth muscle cells and distorted endothelial layer. Immunocytochemistry, using an antibody against prostacyclin (PGI2), detected PGI2 immunoactivity in the ITA smooth muscle cells. An in vitro assay performed on the arterial rings confirmed preserved functional integrity of the vascular endothelium and smooth muscle. These findings suggest that cryopreserved ITA may have potential as a substitute graft, in devising conduit strategies for primary or reoperative coronary bypass surgery.

BACKGROUND AND AIMS OF THE STUDY:The selection of an appropriate size aortic valve substitute with respect to patient size and life-style, in the presence of a small aortic root, is problematic, and a decision to enlarge the aortic annulus is often arbitrary. An aortic valve substitute-patient mismatch may place an excessive load on the left ventricle resulting in residual left ventricular mass with attendant patient morbidity and mortality. The aim of this study was to assess the adequacy of the Medtronic Hall valve in the small aortic root using ultrafast computed tomography analysis of left ventricular mass.MATERIALS AND METHODS:In 13 patients the smallest Medtronic Hall valves (size 20 and 21; measured internal orifice area of 2.01 cm2 for both) were used to replace the native aortic valve. All patients had aortic stenosis, and left ventricular hypertrophy was established by echocardiography. The mean body surface area was 1.8 +/- 0.2 m2 (range 1.50-2.06 m2) and the mean weight was 75 +/- 15 Kg (range 50-97 Kg). The mean preoperative New York Heart Association functional class was 3.54 +/- 0.5.RESULTS:There was no operative or late mortality. At a mean follow up of 22 months after aortic valve replacement, the mean left ventricular mass index was 89 +/- 11.4 g/m2 (normal left ventricular mass index by ultrafast computed tomography = 97 +/- 14 g/m2) and mean New York Heart Association functional class was 1.6 +/- 0.8 (p (Binomial) = 0.0001 compared to preoperative). Doppler echocardiogram demonstrated a mean gradient across the prosthetic valve of 17 +/- 7 mmHg. There was no trend towards greater left ventricular mass index in patients with greater body surface area or weight. In no patient was the aortic annulus enlarged.CONCLUSIONS:Trends from this preliminary data suggest that implanting the smallest Medtronic-Hall aortic valves (sizes 20 and 21) results in normal left ventricular mass following aortic valve replacement in patients up to a body surface area of 2.06 m2 and provides support for the notion that an aortic annulus enlarging procedure was not necessary in this group of patients.

The right atrial approach for repair of ventricular septal rupture associated with myocardial infarction is an alternative technique to the conventional approach of exposing the septum through the left ventricle. This technique may be combined with mitral valve replacement, infarct excision, or aneurysm resection, by avoiding a direct incision in the ventricle reduce postrepair bleeding and impairment of ventricular contractile function. We present a case of ventricular septal rupture repaired through the right atrium and review our surgical technique. This technique may be applied to most cases of ventricular septal rupture, and is particularly useful when the ventricular wall is not infarcted or aneurysmal, and the defect involves the central portion of the muscular septum, the inlet septum, and the subaortic and membranous area.

The case of a patient undergoing successful resection of an interatrial septal paraganglioma is presented. The diagnosis of an interatrial mass was established preoperatively by echocardiography, ultrafast cine computed tomographic scan, and cardiac catheterization. The tumor was excised in total, and the interatrial septum and the roof of the left atrium were reconstructed using a bovine pericardial patch.

The hemostatic properties of fibrin sealant have been well described. Previously published reports have attempted to clarify the possible role of fibrin glue in the inhibition of the formation of intrapericardial adhesions following cardiac surgery. Earlier work hypothesized that fibrin glue may reduce the severity of postoperative adhesions and that the use of autologous fibrin glue may have similar effects, without the risks that accompany homologous blood products. Six juvenile farm pigs were utilized to test this hypothesis. Conventional fibrin glue and single-donor fibrin glue were tested in open-heart surgery. This experimental model was also reexamined and found to be of significant utility in simulating adult reoperative cardiac surgery. The fibrin glue subjects were universally easier to reoperate due to fewer adhesions, as demonstrated grossly and histologically. The single-donor fibrin glue had no significant advantage on adhesion formation, when compared to the conventional fibrin glue group, but the ramifications of formulating fibrin glue in this fashion offer a significant benefit toward the complete use of autologous blood products in open-heart surgery.

The pulmonary valve homograft (PH) has been reported to have potential advantages over the aortic valve homograft, including a larger diameter, a thinner wall, and decreased intrinsic calcification. From January 16, 1986, to July 14, 1987, eight consecutive patients underwent repair of congenital cardiac anomalies using a cryopreserved PH. Patients ranged in age from 18 months to 32 years. Diagnoses included tetralogy of Fallot with pulmonary atresia (3 patients); tetralogy with absent pulmonary valve (1 patient); corrected transposition with pulmonic stenosis (1 patient); transposition of the great arteries, ventricular septal defect, and pulmonic stenosis (2 patients); and double-outlet right ventricle with pulmonic stenosis (1 patient). The PH was implanted orthotopically in the patient with absent pulmonary valve, and in the other 7 it was placed as a valved extracardiac conduit. Two of the tetralogy patients with severe bifurcational pulmonary stenosis and another with nonconfluent pulmonary arteries and origin of the left pulmonary artery from a patent ductus arteriosus had their repairs facilitated using the branching pulmonary arterial portion of the PH. There were no hospital or posthospital deaths. Postrepair right ventricular to left ventricular systolic pressure ratios were a mean of 0.35 at 18 hours postoperatively (range, 0.21–0.61). All patients were studied with Doppler and echocardiography after repair. The mean gradient across the PH was 9 mm Hg (range, 2–27 mm Hg), and no pulmonary valve incompetence was present. One patient (12.5%) required reoperation seven months after repair for conduit revision due to compression by the sternum and is now well. We conclude that the PH is a good conduit for ventricular outflow tract reconstruction, and the short-term results are satisfactory. The bifurcational portion of the donor pulmonary arteries has proved to be useful in the repair of associated pulmonary arterial anomalies. Because of its ready availability when procured in conjunction with the aortic homograft valve, and because of increased demand on our tissue bank for the use of aortic homograft valves, we have adopted the PH as our valve of choice for ventricular outflow tract reconstructive procedures.

BACKGROUND:With important demographic changes in cardiac surgical practice, more older patients are undergoing complex cardiac operations. Controversy exists as to whether the expenditure of healthcare resources on the growing elderly populations represents an effective approach in maintaining a meaningful quality of life.METHODS:From January 1982 through April 1991, 121 consecutive octogenarians underwent a surgical procedure that included coronary artery bypass grafting. Retrospective review of patient medical records was performed; follow-up information was obtained via telephone contact with the patient, the patient's family, or the patient's physician.RESULTS:There were 67 men (55%) and 54 women (45%). Mean age was 82.1 years (range, 80 to 89 years). Sixty-nine percent of the patients were having class III or IV symptoms. There were 11 hospital deaths (9.1%); risk factors included longer cardiopulmonary bypass time (p = 0.01), higher preoperative left ventricular end-diastolic pressure (p = 0.02), advanced age (p = 0.05), history of renal disease (p = 0.02), and myocardial infarction (p = 0.04). Late death occurred in 34 patients (30.9%) at a mean of 27 months postoperatively; univariate risk factors included chronic obstructive pulmonary disease (p = 0.009), higher left-ventricular end-diastolic pressure (p = 0.03), and recent myocardial infarction (p = 0.03). Actuarial survival, including hospital death, was 32.8% at 80 months, compared with 37.6% for an age; sex; and race-matched population (p > 0.3). Most late survivors (84%) were in New York Heart Association class I or II.CONCLUSIONS:We conclude that coronary artery bypass grafting can be performed in octogenarians with an acceptable, although increased risk. Hospital survivors have a good late functional status but are at risk for pulmonary and other atherosclerosis-related events, which impair overall survival.

Background. There is increasing interest in the use of continuous arteriovenous hemofiltration/dialysis for treatment of profound renal failure after cardiovascular operations. Vascular access for this is usually accomplished by percutaneous cannulation of the femoral artery and vein, with the inherent risks of vascular trauma, patient immobilization, hemorrhage, or infectious complications.Methods. Fifteen (0.36%) of 4,166 patients receiving cardiovascular surgical procedures sustained postoperative renal failure requiring treatment with continuous arteriovenous hemofiltration/dialysis. Each patient had creation of acute arteriovenous forearm access using a modified Allen-Brown shunt. Shunts were monitored continuously for hemorrhage, malfunction, infection, and thrombus, and were explanted when no longer required.Results. Sixteen shunts were implanted in 15 patients over the 41-month period. All shunts functioned satisfactorily, with the duration of implantation ranging from 1 to 64 days. There were no infectious or hemorrhagic complications.Conclusion. The acute creation of a simple forearm shunt for postoperative continuous arteriovenous hemofiltration/dialysis is preferred over femoral arterial and venous cannulation because it can be constructed rapidly and easily in the operating room or at the bedside, has a low complication rate, is available for immediate use, may be left in place indefinitely, does not interfere with patient mobilization or ambulation, and is easily removed.