Predicting survival after coronary revascularization for ischemic cardiomyopathy.

Background: The success of coronary revascularization for ischemic cardiomyopathy (left ventricular ejection fraction of 0.25 or less) has been unpredictable. We and others have demonstrated that the hospital operative mortality rate for these operations has been surprisingly low, particularly if evidence of ischemia is present.

Stroke rate is markedly reduced after carotid endarterectomy by avoidance of protamine.

Purpose: Postoperative neurologic injury remains a significant risk of carotid endarterectomy. Mechanisms include embolization of debris and formation of thrombus on the newly endarterectomized surface. We hypothesized that the risk of postoperative neurologic injury would be lower in those patients who did not receive protamine for reversal of heparin anticoagulation.

Pulmonary function after non-heart-beating lung donation in a survival model.

Background: Lung procurement from recently deceased cadavers has been suggested to enlarge the limited donor pool. We hypothesized that lungs harvested from non-heart-beating donors (NHBD) would function as well as those harvested from heart-beating donors.

Methods: Sixteen adult swine underwent left lung allotransplantation.

General surgical complications can be predicted after cardiopulmonary bypass.

Objective: The authors review the general surgical complications of cardiopulmonary bypass, including newer procedures such as heart and lung transplantation, to identify patients at higher risk.

Summary Background Data: Although rare, the general surgical complications of cardiopulmonary bypass are associated with high mortality. The early identification of patients at increased risk for these complications may allow for earlier detection and treatment of these problems to reduce mortality.

Percutaneous transluminal angioplasty of visceral arterial stenoses: results and long-term clinical follow-up.

Purpose: To determine the efficacy and safety of percutaneous transluminal angioplasty (PTA) of the visceral arteries.

Patients And Methods: We retrospectively evaluated the results of PTA performed in 20 visceral arteries in 19 patients (10 men, nine women; mean age, 63 years). Eleven patients had symptoms characteristic of mesenteric ischemia, four had atypical abdominal pain, and four were undergoing prophylactic dilation before undergoing another procedure involving the abdominal aorta.

Compensatory growth of porcine right lungs after chronic rejection of transplanted left lungs.

Neonatal lung hypoplasia is frequently a fatal condition often associated with congenital diaphragmatic hernia. Unilateral lung transplantation rarely has been performed for this indication, although it is a potential solution. It is not known whether the transplant needs to function permanently or to act as a bridge until the native lung develops.

Prevention of spinal cord injury after repair of the thoracic or thoracoabdominal aorta.

Spinal cord injury occurring as the result of surgical repair of thoracic and thoracoabdominal aortic disease remains a devastating complication. The incidence of postoperative neurologic deficits varies from 4% to 38%. Factors associated with a greater risk for injury include the presence of dissection or extensive thoracoabdominal disease, and a prolonged cross-clamp time.

Ambulatory intraaortic balloon counterpulsation.

A technique is described for the retroperitoneal placement of a balloon pump that preserves patient mobility. This technique may be superior to standard femoral placement when prolonged support is required for cardiac transplant candidates awaiting donor organs.

Managing pain during mediastinal chest tube removal.

Objective: To compare four analgesic regimens used in preparing patients for chest tube removal.

Design: Prospective, randomized, controlled multiple-group comparison.

Setting: Mid-atlantic university affiliated tertiary medical center.

Management of renal tumors involving the inferior vena cava.

Purpose: We reviewed our experience of the resection of renal tumors involving the inferior vena cava (IVC) from 1987 to 1992 with the hypothesis that retrohepatic IVC involvement of renal tumors can be managed without cardiopulmonary bypass (CPB) and circulatory arrest with acceptable morbidity and mortality rates.

Methods: We retrospectively reviewed our experience of radical nephrectomies for renal tumors from 1987 to 1992 (n = 69). Of these, 13 had involvement of the IVC (19%).

Optimal timing of abdominal aortic aneurysm repair after coronary artery revascularization.

Objective: The authors ascertained the optimal timing of repair of an abdominal aortic aneurysm (AAA) after coronary artery revascularization.

Summary Background Data: Cardiac events are the most common cause of death after elective repair of AAA. Preoperative coronary revascularization has significantly reduced postoperative cardiac complications after elective AAA repair.

Use of video-assisted thoracic surgery in the treatment of chylothorax.

Chylothorax, a potentially lethal disorder that may cause profound respiratory, nutritional, and immunologic complications, has become increasingly common in recent years. Medical therapy has been found to have a significant failure rate. Therefore, surgical treatment of complicated chylothorax has become a mainstay of care.

Successful use of undersized donors for orthotopic heart transplantation--with a caveat.

Accepted clinical practice has been to require body weights to be within 20% as a criterion for matching donor to recipient for cardiac transplantation. From November 1989 through September 1993 we began accepting larger differences in body weight between donor and recipient with 80 orthotopic heart transplants performed. Twenty-eight of these transplants used undersized donors (donor-to-recipient body weight ratio [DRBW] of 0.

Analysis of airway function of immature whole lung transplants versus mature lobar transplants.

For the pediatric patient with end-stage lung disease in need of transplantation, two potential donor options currently exist: size-matched immature whole lungs or reduced-size mature lobes. To determine which of these options provides superior long-term function, we studied airway mechanics in a chronic porcine model of pediatric lung transplantation. Three groups of animals were studied: the first group underwent left upper lobectomy at 9 +/- 1 weeks of age (innervated left lower lobes).

Complete prevention of postischemic spinal cord injury by means of regional infusion with hypothermic saline and adenosine.

Spinal cord injury after operations on the descending thoracic and thoracoabdominal aorta remains a persistent clinical problem. Previous attempts to decrease the risk of this devastating complication by lowering the rate of metabolism of the spinal cord have met with varying success. We hypothesized that the tolerance of the spinal cord to an ischemic insult could be improved by means of adenosine.

Limiting ischemic spinal cord injury using a free radical scavenger 21-aminosteroid and/or cerebrospinal fluid drainage.

Traumatic spinal cord injury occurs in two phases: biomechanical injury, followed by ischemia and reperfusion injury. Biomechanical injury to the spinal cord, preceded or followed by various pharmaceutical manipulations or interventions, has been studied, but the ischemia/reperfusion aspect of spinal cord injury isolated from the biomechanical injury has not been previously evaluated. In the current study, ischemia to the lumbar spinal cord was induced in albino rabbits via infrarenal aortic occlusion, and two interventions were analyzed: the use of U74006F (Tirilazad mesylate), a 21-aminosteroid, and cerebrospinal fluid (CSF) drainage.

Regional adenosine attenuates postischemic spinal cord injury.

Purpose: Operations on the thoracic and thoracoabdominal aorta are associated with postoperative paraplegia rates as high as 20% to 30%. Attempts to reduce this complication have focused on decreasing the energy needs of the spinal cord with protective agents such as hypothermia and barbiturates or on increasing blood flow with various shunts. This study explores the hypothesis that perfusion of the spinal cord with hypothermic solutions or with adenosine will prevent or ameliorate paraplegia.

Thoracoscopic diagnosis and treatment of mediastinal masses.

Evaluation of mediastinal masses often involves an array of imaging procedures and percutaneous biopsy techniques. Despite this, surgical intervention with an open biopsy is often required, especially to diagnose mediastinal malignancies. We report 22 patients with mediastinal masses who were managed with thoracoscopic biopsy, as opposed to open biopsy.

Use of a Dacron cuff to decrease bleeding from atrial cannulas of ventricular assist devices.

The use of ventricular assist devices is becoming more common for postcardiotomy cardiogenic shock and as a mechanical bridge to transplantation. Bleeding is the most common complication reported in most clinical series. The sources of bleeding are multiple, but our experience is that a substantial percentage occurred from cannulation sites.

Thoracoscopic surgery for diseases of the lung and pleura. Effectiveness, changing indications, and limitations.

Objective: This study compared the results of video-assisted thoracic surgery (VATS) with thoracoscopic surgery (TS) for diseases of the lung and pleura.

Summary Background Data: No studies exist that compare the capabilities of VATS with advanced video systems and instrumentation to that of TS which has been done for 80 years.

Methods: A retrospective study was done comparing the effectiveness, indications, complications, and limitations of TS and VATS done for four categories of pleural disease: 1) pleural fluid problems, 2) diffuse lung disease, 3) lung masses, and 4) pneumothorax.

Successful transplantation of marginally acceptable thoracic organs.

Objective: This study evaluates the efficacy of personally inspecting marginal thoracic organ donors to expand the donor pool.

Summary Background Data: The present donor criteria for heart and lung transplantation are very strict and result in exclusion of many potential thoracic organ donors. Due to a limited donor pool, 20-30% of patients die waiting for transplantation.

Edlich's academical village.

Dr. Richard F. Edlich, Distinguished Professor of Plastic Surgery and Biomedical Engineering, recently received the Thomas Jefferson Award, the highest honor that can be bestowed upon a faculty member at the University of Virginia.

Biomechanical performance of new vascular sutures and needles for use in polytetrafluoroethylene grafts.

Two new cardiovascular monofilament sutures attached to taper point needles have been developed for use in expanded polytetrafluoroethylene (PTFE) grafts. One monofilament suture made of PTFE has a microporous structure that allows it to be channel swaged to a needle that closely approximates its suture diameter. The other suture is a monofilament polypropylene suture that has been extruded to produce a tapered swage end, which was significantly smaller than that of the remainder of the suture in order to be channel swaged to smaller diameter needles.