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Left ventricular outflow tract obstruction after mitral valve replacement may occur when a retained native anterior leaflet prolapses between prosthetic struts. Existing reports of left ventricular outflow tract obstruction by this mechanism lack emphasis on its surgical treatment. We obtained definitive relief of left ventricular outflow tract obstruction by transaortic exposure, division, and partial excision of the obstructing leaflet. This approach minimizes the complexity and potential morbidity of the correction.

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One hundred thirteen patients undergoing cardiopulmonary bypass were randomly assigned to receive either bovine or porcine heparin. Heparin was infused at 4.5 mg/kg during bypass and administered at the lesser of 70 units/kg or 5000 units/dose at 12-hour intervals postoperatively. Platelet counts decreased to 45% of preoperative levels during the first 3 days postoperatively (porcine, 44 +/- 13%, n = 50; bovine, 46 +/- 15%), but returned to preoperative levels by the seventh postoperative day. The average blood loss in the porcine heparin group significantly exceeded that of the bovine heparin group (porcine, 1350.7 +/- 727.8 ml; bovine, 1059.6 +/- 381.0 ml; p less than .01). Consequently, the platelet transfusion requirement was greater in the porcine heparin group (porcine, 1.7 +/- 3.9 units; bovine, 0.5 +/- 1.7 units; p less than .05); however, blood and blood component (with the exception of platelets) administration was not significantly different between the two groups. The four patients taking anticoagulants or antiinflammatory agents in the porcine group required a mean of 8.5 units of red blood cells (RBC) plus supplemental platelets. The seven such patients in the bovine group received a mean of 3.0 units of RBC and no platelets. Thus, the use of porcine heparin resulted in a generalized increase in postoperative bleeding with increased management problems in patients undergoing cardiopulmonary bypass.

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Postcardiotomy sternal infection occurred in 20 (2%) of 1007 patients undergoing cardiac surgery between September 1985 and December 1987, a 10-fold increase over the preceding 33 months (4 [0.24%] of 1627 patients). Cultures were sterile in 5 patients and yielded staphylococci in 12 and a variety of bowel organisms in 3. The cause for the increased occurrence of sternal wound infection is unclear after multivariate analysis, although infections have precipitously dropped subsequent to changing to cefuroxime sodium antibiotic prophylaxis. Treatment has evolved to appropriate antibiotics and early débridement of involved sternum and cartilage. Rewiring the sternum is not attempted. If gross purulence is not present, primary closure is accomplished using muscle flaps (2 patients) or omental pedicle grafts (17 patients). In the presence of gross purulence, the wound is packed open for 5 days and then closed in the above fashion. Two patients required skin grafts for primary closure. The omental pedicle flap is preferred due to simplicity and improved coverage of the sternal defect inferiorly. Nineteen patients healed primarily. A superficial wound infection was drained in 1 patient. Midline incisional hernias developed in 3 muscular patients. Omentum is now harvested through a left subcostal incision. Hospital stay was under 2 weeks in 13 patients. One death occurred due to multisystem failure prior to completion of wound closure. In our experience, early sternal débridement and omental pedicle grafting with primary closure is appropriate therapy for postcardiotomy sternotomy infections. The presence of gross purulence may require 5 days of open packing prior to omental grafting. No significant complications occurred, and mortality was low. A left subcostal incision for omental harvesting is utilized to avoid the occurrence of delayed incisional hernias.

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During an 11 1/2-year period, 20 consecutive patients presenting with a traumatic disruption of the proximal descending aorta underwent an emergency operative repair. The mean age was 26 years (range 15 to 62), and 13 (65%) were male. Associated injuries were frequent and required additional major operative procedures in half of the cases. Two patients died as a result of associated intracranial injuries, for a hospital survival of 90%. The operative repair was accomplished by graft replacement of the involved segment of the aorta in all but one patient who underwent a primary repair. Simple aortic crossclamping was used in 8 patients (40%) and heparinless femoral-femoral venoarterial bypass in 12 patients (60%). Neither renal failure nor paraplegia in any of the patients. Four patients required thoracic reoperations. These results indicate that an aggressive multidisciplinary surgical approach can produce favorable results in patients with traumatic descending aortic injuries.

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Systemic hypothermia became a major problem in one of our patients undergoing postcardiotomy mechanical circulatory support with a centrifugal pump. We have developed a technique to prevent systemic hypothermia in this setting by applying an adapted topical cardiac cooling device to the centrifugal pump heads.

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Between February 1973 and December 1986, 4,787 patients underwent open heart surgery at Samuel Merritt Hospital. Retrospective analysis revealed 395 (8 percent) consecutive patients who required hemodynamic support with the intraaortic balloon pump. Thirty percent of the patients had preoperative placement, 56 percent needed the balloon in order to wean from cardiopulmonary bypass, and 14 percent required placement in the postoperative period. The intraaortic balloon pump was instituted with multiple techniques and insertion sites. Three hundred eighty-three balloon catheters (96 percent) were inserted through the groin by surgical cutdown or a percutaneous approach. The remaining devices were inserted through the aortic arch. A 12 F. catheter was utilized in 239 patients (61 percent) and a smaller 10.5 F. catheter was placed in 156 patients (39 percent). The hospital mortality rate was 47 percent. Seventy-two of the 395 patients (24 percent) sustained vascular complications related to balloon use. Major complications occurred in 43 patients. Twenty-nine patients sustained minor complications that resolved spontaneously with balloon removal. Risk factors evaluated included patient gender, New York Heart Association class, catheter size, method of introduction, duration of counterpulsation, and presence of symptomatic peripheral vascular disease. Since percutaneous placement was associated with a significant decrease in complications, we concluded that use of the smaller 10.5 F. catheter placed percutaneously is the safest means of employing the intraaortic balloon pump. A monitoring line is placed percutaneously through the femoral artery in high-risk patients before operation. This allows easier access for intraaortic balloon pump placement in hypotensive patients. The presence of a clinical history of peripheral vascular disease was also a highly significant risk factor for vascular complications. Other risk factors increasing the likelihood of vascular compromise included catheter size and duration of counterpulsation.

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Bronchopleural cutaneous fistulas are a serious problem that are difficult to treat with any assurance of success. Thoracoplasty, muscle pedicle grafts, and attempts at reclosure have been used with limited success. We have used the omental flap technique in the management of five patients with bronchopleural cutaneous fistulas. In our patients and in four cases in the literature, the success rate has been 100 percent. The omental pedicle flap is a simple way to close bronchopleural fistulas. It avoids extensive chest wall dissection and destruction in patients who often have marked respiratory embarrassment and other underlying disease. The results have been excellent.

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Two hundred seven consecutive patients were randomized into four groups based on left ventricular end-diastolic pressure and subsequently into groups receiving crystalloid cardioplegia or blood cardioplegia. Hemodynamic data and enzymatic evidence of myocardial ischemia were examined postoperatively. We found slight but significant improvement in the blood cardioplegia group regarding left ventricular stroke work index. Similarly, the levels of creatine kinase and serum glutamic oxaloacetic transaminase were slightly but significantly better with blood cardioplegia. We believe that the technique of blood cardioplegia offers a slight but statistically significant advantage.

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A woman with intravenous leiomyomatosis experienced syncope 7 years after a total abdominal hysterectomy and oophorectomy for a uterine fibroid. The workup revealed a tumor that extended from the iliac veins to the right ventricle. It was totally removed under cardiopulmonary bypass. One year later, the patient was found to be asymptomatic and without evidence of tumor recurrence.

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A significant amount of red blood cells were conserved with use of the Cell Saver in cardiac surgery patients and in some orthopedic and vascular surgery patients. No major complications have been associated with its use in our cases. Our results are similar to those of others who have reported on the use of this device. In the cardiac surgery patients we observed significant serum protein losses which had to be replaced. We recommend the use of intraoperative albumin to help maintain adequate urinary output and hemodynamic stability.

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Presently we favor heparinless femorofemoral venoarterial bypass for all descending thoracic aneurysm resections. The advantages are minimal blood loss due to the absence of heparin, ease of insertion, especially in large aneurysms where it would be difficult to insert a temporary shunt, distal aortic perfusion, possibly a safety factor in preventing spinal cord and visceral ischemia, and prevention of left heart overload and myocardial failure. In acute traumatic ruptures, simple aortic cross clamping is a suitable alternative. It is safe and can be carried out expeditiously in any community hospital where bypass facilities may not be available. Proximal hypertension can be controlled pharmacologically. We have also used this successfully in ruptured atherosclerotic aneurysms. We have no experience with temporary tridodecylmethylamonium (TDMAC) shunts; several groups have used them successfully. We believe they may be difficult to insert in the proximal aorta with a large mediastinal hematoma or extensive aneurysm. Cannulation of the left ventricular apex necessitates cardiac manipulation and may produce effective aortic valve insufficiency. In patients with aortoesophageal and bronchoesophageal fistula, permanent extrathoracic bypass is preferable to a prosthetic graft in a contaminated field. We propose using a permanent bypass with a no. 10 or 12 right axillofemoral bypass. Our experience is limited to only two patients. This is also a method of treating a mycotic aneurysm or infected thoracic aortic graft.

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In an attempt to use the benefits of controlled circulatory bypass, while avoiding systemic heparinization and bypass circuitry placed in the operative field, we used heparinless femoral venoarterial bypass without an oxygenator for resection of aneurysms of the descending thoracic aorta. Since 1974 we have applied this technique on 29 patients with excellent results (survival 27-29, 93 percent). Using PPG tubing, mixed venous blood was drained from the right atrium by way of a long catheter inserted via the femoral vein, and returned to the femoral artery by a roller pump. Advantages include distal aortic perfusion, a safety factor in avoiding spinal cord ischemia; preload control, helpful in managing proximal aortic hypertension; avoidance of heparinization; an operative field free of bypass circuitry; and the operation can be performed in an unhurried fashion.

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Following cardiac operations, 145 patients were treated with either intermittent positive-pressure breathing (IPPB), blod bottles, or an incentive spirometer in an attempt to alter the incidence of atelectasis. Pulmonary complications occurred in 30% of the patients receiving IPPB, 15% of those using an incentive spirometer, and 8% of those using blow bottles. Gastrointestinal side-effects occurred in 20% of the IPPB group and were rare in other groups. The cost of IPPB is also considerably greater than either incentive spirometry or blow bottles. IPPB is not essential to prevention of atelectasis in postoperative cardiac surgical patients and may be inferior to other methods.

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A study of the internal configuration of saphenous vein--to--coronary artery anastomoses was undertaken to examine the effect of technical factors. One hundred fifty anastomoses were constructed in isolated swine hearts and epoxy-resin casts were made of the anastomoses by pressure-injection. The effects of interrupted sutures, continuous suture, vein tailoring, vein-to-artery size ratio, and end-to-side and side-to-side anastomoses were evaluated. We made several observations: (1) The external appearance of an anastomosis is not a reliable indicator of internal configuration. (2) Interrupted suturing consistently produces an internal configuration with minimal deformity. (3) Unless special precautions are taken with continuous suturing, severe deformities may occur. Very fine suture spacing and knotting distal corner sutures are recommended. (4) Proper vein-to-artery size ratio and "cobra-head" vein tailoring are desirable. (5) Side-to-side anastomoses are similarly significantly affected by suture techniques, vein graft size, venotomy size, and orientation. The study of the internal configuration of saphenous-coronary anastomoses is a simple and readily available method which should be useful to all coronary surgeons in assessing and perfecting their techniques.

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Heparinless femoral venoarterial bypass without an oxygenator has been used for surgery in 11 patients with aortic lesions requiring cross-clamping of the descending thoracic aorta. Mixed venous blood circulates in the lower half of the body and proximal hypertension is controlled. Surgical time is not rushed, and the bleeding of heparinization is avoided. All patients are well.

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Traumatic interruption of the phrenic nerve causing diaphragmatic paralysis occurs much more commonly than realized. Patients present with symptoms referable to the respiratory, gastrointestinal, or cardiovascular systems as a result of anatomic displacement of the respective organ (eventration). Symptoms often occur shortly after the injury but may be delayed for many years; consequently, prolonged follow-up of these patients is essential. If patients are symptomatic after trauma, judicious observation is dictated, since many will experience gradual return of normal diaphragmatic function over the succeeding six to twelve months. In those who remain significantly symptomatic, thoracotomy and imbrication of the eventration is a simple and effective surgical procedure.

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