A current appraisal of coronary bypass surgery.
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Coronary Artery Bypass↗
Biomedical subjects
C R Hatcher
Publications and source records attributed to C R Hatcher.
Hemodynamic and clinical evaluation of the Hancock xenograft bioprosthesis of aortic valve replacement (with emphasis on management of the small aortic root).
One hundred twenty-nine consecutive patients underwent isolated aortic valve replacement with the Hancock porcine xenograft between July, 1974, and December, 1976. The hospital mortality rate was 3.9 percent. No patient was treated with anticoagulants, and valve-related complications were extremely rare. The smaller prosthetic sizes (19 and 21 mm. stent diameter) should be used with extreme caution, and the 19 mm. prosthesis should probably never be used in the audult patient. Two methods of managing the small aortic root are emphasized: one to avoid using the smaller prosthetic size in adults and the other to alter greatly the root size in children who have a hypoplastic aortic annulus. Acceptable calculated orifice sizes and left ventricular--aortic (LV-Ao) pressure gradients may be obtained with the 23 mm. or larger prostheses. Actuarial survival curves show 92 percent of patients alive and well at 24 months' follow-up.
Adolescent↗
Results of coronary revascularization in patients with recent myocardial infarction.
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Arrhythmias, Cardiac↗
Diaphragmatic eventration in infancy and childhood.
Eventration of the diaphragm, although a relatively rare clinical entity, should be considered in all patients with respiratory distress during the neonatal period, particularly in babies born after difficult delivery by breech presentation or forceps extraction. The diagnosis can be made in the majority of spontaneously breathing patients by chest roentgenography or by fluoroscopy. The treatment initially should be supportive, including assisted ventilation if needed. If the infant cannot be weaned off the respirator after a week to ten days of respiratory support, surgical correction of the elevated diaphragm should be carried out. The results of surgical treatment in these desperately sick infants is usually most gratifying.
Child↗
Concomitant aortic valve replacement and myocardial revascularization.
Twenty-six consecutive patients underwent combined aortic valve replacement and myocardial revascularization at the Emory University Affiliated Hospitals between May, 1973 and March, 1976. Acute myocardial infarction resulted in two operative deaths (8%). There have been four late deaths, all Class IV preoperative. The age range was 37 to 79 years with an average age of 60. Preoperatively all patients were Class IV or late Class III. Twenty-three patients had symptoms of angina pectoris; congestive heart failure was evident in 56%. Postoperatively, 70% are now Class 1 or II. Single coronary bypass was performed in 16 patients, double in 6, and triple in three. Double bypass plus mitral valve replacement was required in two with aneurysmectomy in one. The rate of intraoperative infarction was 27% for the series but only 7% in the last year. The methods of intraoperative myocardial preservation and the technical approach for the operative procedures were variable. Results with each method are correlated, and currently preferred techniques are presented and discussed. Best results were obtained in patients who presented early in their symptomatic course with isolated proximal coronary lesions and good renoff vessels. Excellent results could be achieved despite advanced age of patients, requirement for multiple bypass grafts, and correction of other associated cardiac lesions. Poorest results were obtained when long-standing ventricular failure was combined with poor vessels distal to coronary stenoses.
Adult↗
Benign tumors of the esophagus: experience with 20 cases.
Benign tumors of the esophagus are rare and require an alert suspicion for early diagnosis. These tumors may not cause symtoms before attaining large size, yet they may prove fatal when small. Because of the possibility of malignancy and their tendency to obstruct, benign tumors of the esophagus should be resected when diagnosed. This report details our experience in 20 patients with benign esophageal tumors seen at Emory University Hospital between 1955 and 1975. There were 15 men and five women in the group, ranging in age from 17 to 75 years. The tumor series included 13 leiomyomas, four cysts, two cases of multiple polyps, and one case of granular cell myoblastoma. Six of the tumors were asymptomatic; the remaining 14 had symptoms of dysphagia, pain, and hematemesis. In one instance, episodic hematemesis and melena were so severe that they produced hemorrhagic shock. Characteristic radiologic features helped in making the preoperative diagnosis in 18 of the 20 cases. Two patients had coexisting disease masking the presence of the esophageal tumor. Seventeen patients had surgical resection. There were no operative deaths and follow-up results have been satisfactory.
Adolescent↗
Repeat myocardial revascularization for uncontrollable angina after occlusion of prior aortocoronary bypass.
Twelve patients at Emory University Hospital have had repeat myocardial revascularization for recurrent, uncontrollable, disabling angina pectoris after previous coronary artery bypass grafts. The interval betweeen initial bypass procedure and reoperation ranged from six weeks to six years. The native coronary circulation remained unchanged in six, had developed additional proximal (left main) obstruction in four, and had advanced stenosis at the site of former anastomosis in three. Repeat revascularization consisted of new vein graft construction in eight and vein and internal mammary artery graft in four, with an average of 1.9 grafts per patient. There were no deaths. Seven of 12 patients (60%) are now asymptomatic and three of 12 (25%) are significantly improved. Patency of new grafts studied by elective repeat coronary angiography in six patients showed patency of all grafts to the left anterior descending artery and four of six grafts to other vessels. Analysis of the initial graft closures, method for selecting patients to undergo a second procedure, and operative technics believed important in safety of reoperation and avoidance of repeat early graft occlusion are presented.
Adult↗
Autologous blood transfusion during cardiac surgery. A re-evaluation of three methods.
The use of autologous blood transfusion to decrease blood bank requirements and improve coagulation parameters during cardiac surgery is still controversial. This study was undertaken to re-evaluate three methods of autologous blood transfusion. Before bypass, 13 to 15 percent of the patient's estimated blood volume was removed and stored with either CPD or heparin at room temperature and returned via a peripheral vein after bypass. All patients had significant abnormalities in their PTT, PT, and platelet counts after bypass. Heparinized autologous blood removed from the vena cava cannula was the only technique which significantly improved the PTT and platelet count. Total blood bank requirements were significantly less for the autologous blood groups than for controls. There was a saving of 18 percent in banked blood requirements. Fresh frozen plasma and platelets were not found to be routinely needed during cardiac surgery.
Blood Cell Count↗
Propranolol therapy in patients undergoing myocardial revascularization.
The records of 185 consecutive patients having myocardial revascularization were reviewed with regard to preoperative administration of propranolol and intraoperative or postoperative complications. Tachycardia and hypertension before cardiopulmonary bypass were slightly more common in patients never taking propranolol or those who had discontinued it for more than 48 hours before operation. There was no statistically significant difference in the incidence of postbypass hypotension among patients who took propranolol within 24 hours of operation, those who discontinued it more than 24 hours before operation, and those who never took the drug. Operative mortality was not significantly different among patients who received propranolol within 48 hours of operation (3%), those who never took it and those who discontinued it more than 48 hours before operation (4%). Early in the series, five patients had an acute myocardial infarction within 48 hours after routine preoperative withdrawal of propranolol. Because complete withdrawal of propranolol in patients with unstable angina pectoris may lead to acute myocardial infarction, we recommend gradual withdrawal of the drug during 48 hours before operation. If this is not possible because anginal pain recurs or intensifies, then reduced doses may be given safely up to 10 hours before revascularization, provided that the patient is a satisfactory candidate for bypass and that adequate myocardial revascularization can be accomplished.
Adult↗
Sternal osteomyelitis and mediastinitis after open-heart operation: pathogenesis and prevention.
Sternal osteomyelitis and mediastinitis caused by Pseudomonas cepacia developed in a patient undergoing coronary artery bypass two weeks after the operation. P. cepacia bacteremia from a contaminated pressure transducer had preceded and probably caused the chest infection. While other authors have suggested that postoperative sternal osteomyelitis and mediastinitis result from local wound contamination, this case suggests the importance of bacteremia as a cause of such gram-negative infections. Since patients undergoing open-heart operation are exposed to many sources of bacteremia, prevention of severe postoperative chest infections may depend in large part on careful preoperative evaluation of each patienc antibiotic regimens, and, as shown in this patient, on very thorough periodic review of equipment sterilization and intravascular monitoring practices.
Cardiac Surgical Procedures↗
Acute penetrating tracheal trauma.
During the past ten years, 20 patients with acute penetrating tracheal injury (15 cervical and 5 thoracic) have been treated at Grady Memorial Hospital. Ten of the 20 patients had other major associated injuries: 6 had esophageal wounds, 5 had arterial injuries, and 2 had additional wounds. In the first 5 patients treatment of the tracheal injuries consisted of tracheostomy alone. Later on, the tracheal wounds were managed according to type, site, size, and the type of other organ injury. Repair of the tracheal wound and tracheostomy were done in 3 patients, repair of the tracheal wound and temporary tracheal intubation in 4 patients, tracheocutaneous stoma in 1 patient, temporary tracheal intubation alone in 4 patients, and observation alone in 3 patients. Seventeen patients recovered from their injuries and 3 died from sepsis, respiratory insufficiency, or cerebrovascular accident. All 3 deceased patients had other major injuries. This experience suggests that the treatment of penetrating tracheal injury should depend upon the type, size, and site of the wound and the type of coexistent injury to other organs, and that primary repair of the tracheal wound can be carried out in the majority of the patients.
Adolescent↗
Aortic valve replacement: the problem of the small aortic annulus.
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Adult↗
Myxoma of the heart: clinical and experimental observations.
During the past 12 years, 13 patients with atrial (10 left and 3 right) myxoma have been treated. The tumors of the left atrium produced signs and symptoms of mitral valve obstruction and/or subacute bacterial endocarditis and those of the right atrium manifestations of tricuspid valve disease or of pulmonary embolus or hypertension. The diagnosis was established by angiocardiography in 8 patients, at surgery performed for suspected mitral stenosis in 3 patients, and at autopsy in 2 patients. Resection of the atrial myxoma alone in 5 patients or with atrial septum where the atrial myxoma was attached in 4 or with the whole right atrial wall where the atrial myxoma was attached in one patient was performed and all are doing well without evidence of recurrence. Studies of experimentally produced 1.5-3 cm in diameter left atrial thrombus in 30 dogs divided into 5 groups and followed cineangiocardiographically and sacrificed from 14 days to 6 months indicated that the implanted thrombus is absorbed over a 3 to 6 month period. These experimental and human left atrial thrombi were found to be histologically and histochemically different from human atrial myxomas. The electron microscopic studies performed on some of the resected atrial myxomas suggested that the atrial myxoma cells are active cells of endotheilial origin. These observations suggest that atrial myxoma is a primary tumor of the heart which can mimic other clinical entities, and the results of its surgical treatment are gratifying and long lasting.
Angiocardiography↗
The embryology and management of vascular rings.
Among 34 patients with vascular rings, symptoms of tracheal and esophageal compression or both occurred during the first six months of life in 24 (71%). Diagnosis was made in all cases on either plain x-ray film or esophagogram, and was confirmed by operation or angiogram. Associated defects were numerous, with ventricular septal defect (5) and Down's syndrome (3) most common. Operative intervention was required in 18 cases (53%), including 12 of the 14 double arches. Only one of the ten patients with symptomatic recurrent subclavian artery underwent operation. Fourteen of the 18 patients operated upon had early total relief of symptoms, and 17 had excellent late results. A simple system for describing the embryology of vascular rings is presented, and the embryologic relationship between vascular rings and interrupted aortic arches is described. Because of frequent delay in recognition of vascular rings and other surgically correctable lesions, the work-up of every child with two or more episodes of pneumonia should include barium swallow.
Adolescent↗
Cardiac valve replacement in the first 21 years of life.
From 1969 through 1974, 25 patients under age 21 years had prosthetic cardiac vlave replacement at the Emory University Hospital. Twenty-nine valves were replaced in this group. Patients ranged in age from 2 to 21 years, with a mean of 14 years. Concomitant correction of associated cardiac lesions was required in 14 (56%). Five (21%) had had prior open valvuoplastic procedures. Operative mortality for the entire group was 12%, with an additional late mortality of 8%. There have been no early or late deaths in the last three years' experience. Best results are obtained when early correction of isolated valvular lesions is done as soon as clinical deterioration on vigorous medical management is recognized. The presence of multiple intrcardiac lesions or prior valve surgery does not preclude excellent results. Current indications for surgical correction and follow-up management are presented.
Adolescent↗
Atrial septal defect. Review of ten year experience.
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Adolescent↗
A combined surgical approach in the management of achalasia of the esophagus.
The treatment of achalasia at the present time is far from being ideal. The results of pneumatic dilatation have not always been impressive and the risk of esophageal perforation is real. Modified Heller operation has succeded in relieving obstructive symptoms in the majority of patients with achalasia. However, the reported incidence of reflux esophagitis following Heller myotomy is four to 37 per cent. In 25 patients with achalasia followed up to 10 years after Heller myotomy, nine patients had symptomatic reflux and three patients developed esophageal strictures. We believe the addition of an anti-reflux operation should be considered in all patients undergoing operation for achalasia and especially those patients with preoperative symptoms of reflux.
Dilatation↗
An operation for relief of severe left ventricular outflow tract obstruction.
The case history of a 30-year-old man with severe mitral and aortic stenosis and slight aortic regurgitation who underwent replacement of both valves is presented. At the initial surgical procedure, because of the small-size annuli, a small Beall mitral prosthesis and a No. 19 Björk-Shiley aortic prosthesis were used. The subsequent recurrence of severe symptoms and findings of an 80 mm. Hg gradient across the Björk-Shiley aortic valve led to repeat exploration and corrective surgery. The operative procedure to relieve left ventricular outflow obstruction is described. It is felt that this procedure can be used not only for the relief of severe aortic annular stenosis but also for other forms of severe left ventricular outflow tract obstruction such as idiopathic hypertrophic subaortic stenosis and particularly in the patients who have experienced poor results with one of the known surgical procedures for this clinical entity.
Adult↗