Antifibrinolytic therapy in cardiac surgery.

Bleeding remains an important complication after repeat and complicated cardiac surgery. Although aprotinin has recently been approved by the Food and Drug Administration for use as an antifibrinolytic agent, many surgeons continue to have concerns about its added cost and potential side effects. We review here the current state of antifibrinolytic therapy for excessive bleeding in cardiothoracic surgery and suggest the use of a single intravenous dose of 10 g of epsilon-aminocaproic acid immediately before cardiopulmonary bypass as a safe, inexpensive, and effective alternative to aprotinin.

Further experience with exsanguination for descending thoracic aneurysms.

Resection and graft replacement of descending thoracic aortic aneurysms is associated with potential ischemic sequelae related to aortic cross-clamping. Such complications are minimized when the ischemic period is shorter than 30 minutes. We have devised a technique in which a single aortic cross-clamp is applied proximal to the lesion, and the distal anastomosis is performed in "open" fashion, with limited distal aortic dissection.

Graft replacement of the descending thoracic aorta: results of "open" distal anastomosis.

With the advent of rapid autotransfusion, we began to repair aneurysms of the descending thoracic and thoracoabdominal aorta by using an "open" technique, in which a single cross-clamp is placed proximal to the aneurysm to exsanguinate the lower body. To determine whether open distal anastomosis effectively protects against spinal cord injury, we studied 71 consecutive patients (50 men, 21 women) who underwent this procedure beginning in April 1989. The patients ranged in age from 31 to 83 years (mean, 63.

Repair of postinfarction ventricular septal defect.

Recently I successfully repaired a necrotic, acute septal defect by modifying the standard intracavitary repair of postinfarction aneurysm. The technique was modified after a patient who had undergone standard intracavitary repair developed a systolic murmur and had to be returned to surgery, where I found that the continuous suture had become detached at the posterior extent of the repair. The pericardial baffle was reattached using interrupted sutures with felt pledgets.

Improved survival after extended bridge to cardiac transplantation.

In the past, left ventricular assist device (LVAD) support was frequently plagued by complications; thus, bridge to transplantation times were kept short. Increasing evidence suggests that extended bridging provides greater benefit due to improved end-organ perfusion and, thus, generally improved physical condition. To assess whether extended bridging translates into improved long-term survival after transplantation, we reviewed our experience with the HeartMate 1000 IP LVAD (Thermo Cardiosystems, Inc, Woburn, MA).

Transmyocardial laser revascularization. Anatomic evidence of long-term channel patency.

Transmyocardial laser revascularization, a new surgical technique, is being tested in patients with chronic obstructive coronary artery disease that is refractory to conventional revascularization techniques and to maximal medical therapy. During the operation, which is performed on the beating heart through a left thoracotomy, a high-energy CO2 laser is used to bore transmural channels (1 mm in diameter) into the left ventricle. Each high-energy laser pulse is delivered during end diastole and transects the heart within 10 to 60 msec.

Echocardiographic evaluation of anuloplasty rings. Comparison of continuity equation and pressure half-time methods.

This study was undertaken to compare pressure half-time and continuity equation methods in the postoperative evaluation of anuloplasty rings. We performed 2-dimensional echocardiography and Doppler studies in 39 patients who had undergone valve repair for mitral regurgitation. In patients with a pressure half-time of 110 msec or more (9/39), there was no significant difference in calculated valve area between the 2 methods (p = 0.

Aortic valve replacement in patients 80 years and older. Operative risks and long-term results.

Background: Forty percent of 7.4 million Americans aged 80 years and older have symptomatic heart disease. Controversy exists as to whether the health care resources allotted to this patient subset represent a cost-effective approach to attaining a meaningful quality of life.

Current use of substitute heart valves.

Although repair of diseased heart valves became possible in the 1940s, replacement of such valves had to await the development and refinement of the heart lung machine, as well as the advent of serviceable valve substitutes. Early investigators were hindered by the idea that alternative valves should closely resemble anatomic ones. Not until the early 1960s, with the introduction of caged- ball prostheses by Harken and Starr, did effective valve replacement become possible.

Eversion technique for carotid endarterectomy.

Since April 1991, we have used the eversion technique to perform carotid endarterectomy in 31 consecutive procedures. There were no operative deaths in the current series, and no neurologic complications have been observed. We believe this technique decreases the possibility of early and late restenosis and recommend it for patients requiring carotid endarterectomy.

A surgical technique for a delayed hemorrhage after lateral aortorrhaphy.

Stretching of suture material is an infrequent cause of delayed mediastinal hemorrhage after lateral repair of the aorta. In contrast to end-to-end reconstructions, lateral patch repairs of the aorta present unusual stress on the anastomotic suture line. We describe a simple technique for repair of loosened suture lines, with suggestions for preventing this complication in cases of lateral aortic reconstruction.

A cost-effective Dacron annuloplasty ring.

Annuloplasty rings fashioned from Dacron tube grafts have been used in mitral valve operations at the Texas Heart Institute for the past 3 years. This technique has been applied in 70 consecutive patients, with excellent clinical and echocardiographic results. We have found that annuloplasty rings constructed from transverse sections of knitted Dacron offer the same advantages as other flexible rings at a greatly reduced cost.

Computer-guided surgery for tachyarrhythmias in children: current results and expectations.

Objectives: The purpose of this report is to summarize our entire surgical experience in the treatment of tachyarrhythmias in children. We emphasize our application of a newer computerized mapping system for use in both the electrophysiology laboratory and the operating room to localize points of activation of the tachyarrhythmias.

Background: A retrospective review was undertaken to examine the results of operative procedures in 290 children undergoing surgical treatment for tachyarrhythmias from 1977 to the present.

Fungal infection in a dissecting aneurysm of the thoracic aorta.

We describe a 54-year-old man who had an ascending aortic prosthetic graft and a porcine aortic valve prosthesis that were infected by Candida albicans. This infection led to the formation of a dissecting false aneurysm of the remaining transverse and entire descending thoracic aorta, and the man was admitted to our hospital for surgical treatment in February of 1991. Staged in situ graft replacement was performed using Borst's "elephant trunk" repair for the proximal aortic reconstruction and an open distal anastomosis technique for the distal repair.

Simplified techniques of valve replacement.

After an extensive trial of many different suture techniques for implanting valvular prostheses, we have recently returned to using a simple, continuous suture of monofilament polypropylene. We believe this technique has many theoretical and practical advantages. Valvular implantation takes less time and is even more secure than when individual sutures are used.

Technique of open distal anastomosis for repair of descending thoracic aortic aneurysms.

Ischemic injury to the spinal cord and kidneys continues to be the major complication after resection of aneurysms involving the descending and proximal abdominal aorta. Our recent surgical experience with use of only a proximal clamp on the aorta to perform an "open" distal anastomosis has proved this technique to be safe and expeditious. We therefore compared our results using the technique of open distal anastomosis for aneurysm repair with those of the conventional two-clamp technique.

Long-term results of the surgical management of symptomatic chronic intestinal ischemia.

We analyzed our surgical experience in 20 patients who underwent revascularization procedures for symptomatic chronic intestinal ischemia caused by atherosclerosis. The group comprised 17 women and 3 men, with an age range of 25 to 71 years (mean 58.6 years).

Congenital malformations of the coronary arteries: the Texas Heart Institute experience.

Coronary artery anomalies, some of which are considered clinically insignificant, can be associated with other congenital heart defects, myocardial ischemia, and reduced life expectancy. We conducted a retrospective study to determine the efficacy of surgical treatment in 191 patients who had a total of 202 coronary artery anomalies, which were classified as anomalies of origin (88 patients), termination (93), or distribution (10). Of the 88 patients with anomalies of origin, 60 had a coronary artery arising from the pulmonary artery, 18 had a right coronary artery arising from the left anterior descending artery, and 10 had a coronary artery arising from the contralateral sinus of Valsalva.

Spinal cord protection with intravenous nimodipine. A functional and morphologic evaluation.

The purpose of this study is to determine the effects of ischemia in the spinal cord when a calcium channel blocker, nimodipine, is administered intravenously before, during, and after crossclamping of the thoracic aorta. In this series of experiments, 18 pigs underwent thoracotomies and had 17.5 to 18.