Circulatory Support 1988. Patient selection.
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Assisted Circulation↗
Biomedical subjects
D G Pennington
Publications and source records attributed to D G Pennington.
Use of the Pierce-Donachy ventricular assist device in patients with cardiogenic shock after cardiac operations.
In spite of recent improvements in cardiac surgery, a small percentage of patients have severe postcardiotomy ventricular failure refractory to drugs and the intraaortic balloon. In our experience, the Pierce-Donachy external pneumatic ventricular assist device has proved to be one of the most effective devices for these patients. Since 1981, 30 patients aged 15 to 71 years (mean age, 52 years) with profound cardiogenic shock refractory to conventional therapy after cardiotomy were supported with the Pierce-Donachy ventricular assist device. Fourteen required left ventricular support, 7 needed right ventricular support with an intraaortic balloon, and 9 had biventricular assistance. Duration of support ranged from three hours to 22 days (mean length, 3.6 days). Seven of the first 11 patients seen died in the operating room of bleeding, biventricular failure, or both. However, 16 patients (53%) had improved cardiac function, 15 (50%) were weaned, and 11 (37%) were discharged. Of the last 19 patients in the series, 47% survived. Factors affecting survival were myocardial infarction (75%) and renal failure (90%). Common complications were bleeding (73%) and biventricular failure (83%).
Adolescent↗
Implantable electrical left ventricular assist system: bridge to transplantation and the future.
An implantable left ventricular assist system (LVAS) utilizing an electromechanically driven dual pusher-plate blood pump has been employed in a multiinstitutional trial as a bridge to cardiac transplantation. Under development for permanent circulatory support in patients with end-stage heart disease, the LVAS, in this application, derives power and control from an external console via a percutaneous lead. The LVAS was implanted in 20 patients (16 men, 4 women) who were hemodynamically unstable or in refractory cardiogenic shock. The mean age was 44.9 years (range, 25 to 63 years). Preoperative diagnosis was evenly divided between end-stage ischemic disease, cardiomyopathy, and acute myocardial infarction. Implanted in the left upper quadrant within the anterior abdominal wall, the blood pump was connected between the left ventricular apex and ascending aorta. Total support of the systemic circulation and substantial left ventricular unloading were achieved with synchronous counterpulsation for periods up to 90 days (mean, 22.7 days). All patients were stabilized hemodynamically. The mean preoperative cardiac index of 1.5 L/min/m2 increased by a factor of 2. Pulmonary arterial pressures decreased substantially. Serious complications occurred in 16 patients, precluding cardiac transplantation in 10. Most complications (greater than 70%) were in patients who did not receive transplants; the most common complication was bleeding. Twelve of 13 patients with LVAS implants for more than seven days were mobilized, and 4 were fully ambulatory and completely rehabilitated. Orthotopic cardiac transplantation was performed in 10 patients after implants ranging from two to 90 days (mean, 30.3 days).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Left coronary ostial stenosis: comparison with left main coronary artery stenosis.
We compared 147 consecutive patients who had left coronary ostial stenosis with 254 consecutive patients who had left main coronary artery stenosis treated with coronary artery bypass grafting. Mean age for the left main group was 61.6 years versus 59.7 years for the left ostial group (p = not significant [NS]). In the left ostial group, 43.5% were female and in the left main group, 12% (p less than 0.005). Prior myocardial infarction had occurred in 53% of patients with left main stenosis and 36% of patients with left ostial stenosis (p less than 0.005). There were 2.45 +/- 1.00 diseased vessels in the left main group and 1.96 +/- 1.09 in the left ostial group (p less than 0.0005). Seven (3%) of the patients with left main stenosis had no associated coronary disease (greater than 50%) versus 24 (16%) of the left ostial group (p less than 0.005). The degree of left main stenosis was 90% or more in 28.3% of patients versus 42.8% with equivalent ostial narrowing (p less than 0.01). Left ventricular function was better in the left ostial group than in the left main group (1.61 +/- 0.93 versus 2.02 +/- 1.11, respectively; p less than 0.0005). One-month mortality was 10 patients (3.9%) in the left main group and 8 (5.4%) in the left ostial group (p = NS). Perioperative infarction occurred in 8.6% of patients with left main stenosis and 4.7% of patients with left ostial stenosis (p = NS). Mean follow-up was 6.1 years for the left main group and 5.4 years for the left ostial group.(ABSTRACT TRUNCATED AT 250 WORDS)
Aorta↗
Coronary artery bypass grafting for unstable angina pectoris: risk analysis.
Unstable angina pectoris is a broad, nonspecific diagnosis encompassing a wide variety of clinical syndromes. The intravenous administration of nitroglycerin preoperatively is indicative of a more acute clinical situation, and allows for selection and analysis of a more homogeneous patient population. We reviewed the results of coronary artery bypass grafting for unstable angina defined as angina necessitating intravenous administration of nitroglycerin preoperatively. There were 129 patients (83 men and 46 women) with a mean age of 63.2 years (range, 36 to 86 years). Complications included operative death in 6.2%, postoperative low cardiac output in 11%, and perioperative myocardial infarction in 9%. Twenty perioperative variables were analyzed to identify risk factors for these end points. For operative death, age (p less than 0.05), cross-clamp time (p less than 0.05), and cardiopulmonary bypass time (p less than 0.001) were significant in the univariate analysis, but only age (p less than 0.05, F = 4.6) was an independent predictor using multivariate analysis (stepwise linear regression). For low cardiac output, univariate analysis demonstrated that cross-clamp time (p less than 0.01), preoperative use of an intraaortic balloon for angina (p less than 0.05), left ventricular score (p less than 0.05), number of diseased coronary vessels (p less than 0.05), and cardiopulmonary bypass time (p less than 0.001) were significant variables. However, only use of an intraaortic balloon for angina (p less than 0.0001, F = 14.3) and left ventricular score (p less than 0.005, F = 11.1) were significant independent predictors in the multivariate model. For perioperative myocardial infarction, only diabetes requiring insulin (p less than 0.005) was a significant predictor.
Adult↗
Axillary artery insertion of an intraaortic balloon pump.
We describe a technique for insertion of an intraaortic balloon pump through the axillary artery. This approach is useful in patients requiring intraaortic balloon pump support before cardiac transplantation in that it dramatically increases patient mobility while awaiting a donor heart.
Axillary Artery↗
Free-flap reconstruction of large defects of the scalp and calvarium.
Beyond a certain size, full-thickness defects of scalp are not amenable to local flap repair. Staged distant flaps have now been virtually eliminated by free-flap reconstruction. The authors present 12 patients in whom full-thickness scalp defects with an average area of 275 cm2 were reconstructed utilizing free flaps. Nine patients had corresponding large calvarial defects. Ten patients had reconstruction with free latissimus dorsi muscle flaps and overlying skin grafts, and one patient had reconstruction with a scapular free flap. Of the 12 patients, 8 had extirpative surgery for tumor with immediate reconstruction and the remaining 4 had reconstruction for chronic radionecrosis of the scalp, usually associated with infected osteoradionecrosis of the calvarium. Of this latter group, 2 patients underwent simultaneous acrylic cranioplasty. The technique and results are discussed.
Acrylic Resins↗
A critical analysis of extracorporeal membrane oxygenation for congenital diaphragmatic hernia.
Despite advances made in the care of infants with congenital diaphragmatic hernia (CDH), survival remains poor. New therapy, such as extracorporeal membrane oxygenation (ECMO), is controversial but may improve survival. Thirty-two newborns with CDH were treated. Thirteen infants were treated with jugular vein-carotid artery ECMO after CDH repair elsewhere; six (46%) survived. Three of the remaining 19 were moribund shortly after birth and first received ECMO, then underwent repair; two (67%) survived. The other 16 underwent CDH repair; 8 of 9 (89%) recovered with conventional therapy, and 4 of 7 (57%) survived when ECMO was used after conventional therapy failed. Overall survival was 63%. Parameters with which physicians may attempt to predict survival or the need for ECMO after repair--such as A-aDO2, ventilatory index versus PCO2, presence of a "honeymoon period" (PaO2 greater than 100 mm Hg after repair), or oxygenation index--were unreliable. ECMO can improve survival in infants with CDH, probably through reversal of pulmonary hypertension. Presently available methods of predicting survival after CDH repair with or without ECMO are not accurate, and thus no infant should be excluded from repair or ECMO support.
Extracorporeal Membrane Oxygenation↗
Management: by circulatory assist devices.
The current status of mechanical circulatory support in patients with cardiogenic shock is presented in terms of patient and device selection. Advantages of the complications associated with this type of therapy is discussed.
Assisted Circulation↗
Emergency management of cardiogenic shock.
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Assisted Circulation↗
Left subclavian-left coronary artery anastomosis for anomalous origin of the left coronary artery. Long-term follow-up.
From 1972 to 1987, seven patients, from two to 28 months of age, underwent left subclavian artery-left coronary artery anastomosis for anomalous origin of the left coronary artery from the pulmonary trunk. All of these infants, median age 4 months, had severe congestive heart failure caused by anterolateral myocardial infarctions. There were two hospital deaths (29% mortality rate) with no late deaths after an average 10-year follow-up. All survivors have good exercise tolerance New York Heart Association class I), reduction in heart size, and significant improvement or normalization of ventricular function by echocardiography. Patency of the subclavian-left coronary artery anastomosis has been documented in two of four patients who have undergone catheterization. In contrast to other revascularizing procedures for treatment of an anomalous origin of the left coronary artery, anastomosis of the left subclavian to the left coronary artery may be performed without cardiopulmonary bypass or aortic occlusion. Moreover, this procedure appears to have an acceptable mortality rate with excellent long-term functional results in critically ill infants.
Anastomosis, Surgical↗
T cells in ventricular assist device patients.
Levels of T lymphocytes were measured in 20 consecutive patients, 18 men and two women, supported with ventricular assist devices or an artificial heart. Indications for support were bridge to transplantation (n = 10), postcardiotomy cardiogenic shock (n = 8), and acute myocardial infarction shock (n = 2). Control levels were from healthy volunteers not undergoing cardiac operation. Preoperatively, numbers of total lymphocytes and subclasses CD3, CD4, and CD8, as well as the interleukin-2 receptors (IL2R), were the same as controls (cells/microliters): lymphocytes, 1,940; CD3, 1,413 +/- 410; CD4, 894 +/- 318; CD8, 490 +/- 185; IL2R, 96. From implant to postoperative day 5, levels were below control values (p less than 0.001), reaching a nadir on postoperative day 2 (lymphocytes, 896 +/- 599; CD3, 489 +/- 267; CD4, 309 +/- 207; CD8, 183 +/- 107; IL2R, 43 +/- 47). Data from 10 patients (group 1) who survived (four weaned from cardiopulmonary bypass, six transplanted) were compared with those from 10 patients (group 2) who died of multiorgan failure, sepsis, or both. From preimplant through postoperative day 6, levels did not differ between groups. However, from postoperative day 7 to the last day of ventricular support (group 1, 24-90 days; group 2, 7-29 days), group 1 levels (lymphocytes, 2,364 +/- 618; CD3, 1,825 +/- 553; CD4, 1,013 +/- 187; CD8, 796 +/- 402) were significantly above (p less than 0.01) group 2 levels (lymphocytes, 1,290 +/- 463; CD3, 746 +/- 295; CD4, 534 +/- 253; CD8, 221 +/- 106). These data indicate that lymphocytes and particularly T cells 1) decrease after ventricular assist device insertion, reaching a nadir at postoperative day 2, 2) return to control values after patients whose clinical status improves, and 3) remain low in severely ill patients. T-cell depression in ventricular assist device patients is related to the severity of the patient's condition rather than the presence of the device.
Adult↗
Team approach to circulatory support.
A multidisciplinary approach to circulatory support is discussed in this article. The clinical, educational, and investigational responsibilities of each team member are presented.
Ancillary Services, Hospital↗
Heterotopic prosthetic ventricles as a bridge to cardiac transplantation. A multicenter study in 29 patients.
Heterotopic prosthetic ventricles were used to support the circulation in 29 candidates for heart transplantation who were expected to die before procurement of a donor heart. Twenty-one of these patients (average age, 36 years) underwent successful transplantation after 8 hours to 31 days of circulatory support. The other eight patients died because their condition could not be stabilized for transplantation, despite restoration of blood flow. Fourteen patients received biventricular support; 15 received only left ventricular support, with pharmacologic assistance of right heart function. Before transplantation, blood flow from the left prosthetic ventricle averaged 2.8 +/- 0.4 liters per minute per square meter of body-surface area, and from the right prosthesis 2.4 +/- 0.4 liters, as compared with an average flow of 1.6 +/- 0.5 liters per minute per square meter before implantation. Of the 21 patients who received heart transplants, 20 were discharged from the hospital after a median of 31 days. Nineteen patients were alive at 7 to 39 months, and 11 of the first 12 were alive at one year. We conclude that heterotopic placement of prosthetic ventricles as a bridge to transplantation provides an effective method of temporarily supporting cardiac function in critically ill patients without removing the natural heart. The early survival rate after transplantation is similar to that with elective cardiac transplantation.
Adolescent↗
Surgical closure of atrial septal defect in patients older than 50 years of age.
Between 1962 and 1986, 51 patients 50 years of age or older (mean, 59.7 years; range, 50 to 77 years) underwent operative closure of atrial septal defect. The mean pulmonary vascular resistance was 1.7 +/- 0.79 wood units and the mean pulmonary blood flow-systemic blood flow ratio was 2.8 +/- 1.4. Patch closure with pericardium or Dacron was performed in 36 patients (70%), while 15 patients (30%) underwent primary closure. There were no operative deaths, and one patient was not available for follow-up. The remaining 50 patients (98%) have been followed up for 0.5 to 25 years (mean, 9.6 years). Mean preoperative New York Heart Association classification was 2.40 +/- 0.70. This improved significantly to 1.21 +/- 0.42 at follow-up, with all patients improving by at least one category. No patient received long-term anticoagulation treatment, and no pulmonary or systemic emboli were identified. Two (13%) of 15 patients who underwent primary closure developed septal dehiscence. Actuarial survival was 93%, 86%, and 79% at 5, 10, and 15 years, respectively. Atrial septal defect closure can be safely performed in older patients with excellent results, provided the ratio of systemic to pulmonary blood flow is greater than or equal to 1.5 to 1.0, the pulmonary vascular resistance is low, and the shunt remains left to right. Primary closure should be discouraged, and postoperative anticoagulation therapy appears unwarranted.
Aged↗
Dysrhythmias after the modified Fontan procedure.
The cardiac rhythm before and after the modified Fontan procedure was reviewed in 24 patients. Transient atrial dysrhythmias were common in the immediate postoperative period. Late postoperative premature atrial contractions were detected by ambulatory monitoring in 20 of 23 patients; eight (34.8%) had supraventricular tachycardia. Late ventricular dysrhythmia was detected in 18 of 23 patients: ten had low-grade ventricular dysrhythmias and eight (34.8%) had multiform premature ventricular contractions. Five of the latter had couplets and one of these five plus another had ventricular tachycardia. Seven patients with supraventricular tachycardia and five patients with ventricular dysrhythmia required antiarrhythmic medication. Asymptomatic bradycardia was detected in five patients (21.7%). One patient had intermittent second-degree atrioventricular block. No specific risk factors predicted dysrhythmias. Thus, cardiac dysrhythmias were common in patients after the modified Fontan procedure, but were well tolerated in most patients. No sudden deaths or syncopal episodes have occurred during a mean follow-up of 5 years. One patient's death was related to severe left ventricular dysfunction. Permanent pacing has not been required in any patient.
Adolescent↗
Effect of ventricular function on the exercise hemodynamics of variable rate pacing.
To determine the effect of ventricular function on the exercise hemodynamics of variable rate pacing, 16 selected patients underwent paired, double-blind, randomized exercise tests in single rate demand (VVI) or variable rate (VVIR) pacing modes. Ejection fraction and cardiac index were determined by two-dimensional and Doppler echocardiography at baseline and during peak exercise. Baseline ejection fraction ranged from 14 to 73% and was less than 40% in 6 patients (Group 1) and greater than or equal to 40% in 10 patients (Group 2). Duration of exercise was longer during the VVIR mode (502 s) than during the VVI mode (449 s) (p less than 0.01) and unrelated to baseline ejection fraction. Heart rate during exercise increased 9% in the VVI mode and 35% in the VVIR mode (p less than 0.005). Cardiac index increased 49% in the VVI mode and 83% in the VVIR mode. Analysis of variance for repeated measures showed a significant effect of pacing mode (p less than 0.01) and exercise (p less than 0.001), but not baseline ejection fraction, on cardiac index. Baseline ejection fraction did not correlate with the increase in cardiac index in either pacing mode or with the difference in increase between modes. There was no significant difference between Groups 1 and 2 in exercise duration, peak heart rate-blood pressure (rate-pressure) product, baseline or peak heart rate or baseline or peak cardiac index. Therefore, in selected patients, VVIR pacing during exercise results in an increase in heart rate, duration of exercise and cardiac index that is unrelated to the degree of baseline left ventricular dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
The changing profile of the patient undergoing coronary artery bypass surgery.
The first 100 consecutive patients undergoing isolated coronary artery bypass surgery in 1975 were evaluated with respect to the incidence of operative risk factors and outcome. When compared with an identically selected group from 1985, there was significant worsening of the preoperative condition over the decade with regard to mean age (p less than 0.0005), presence of congestive heart failure (p less than 0.05), left ventricular dysfunction (p less than 0.05), severity of coronary artery disease (p less than 0.001) and incidence of emergency operation (p less than 0.05). More patients in 1985 had associated medical diseases such as diabetes (p less than 0.01) and chronic lung disease (p less than 0.005). There was an increase in the occurrence of vascular diseases (hypertension, renal dysfunction, peripheral vascular and cerebrovascular disease) (p less than 0.05). Overall operative mortality increased from 1 to 8% (p less than 0.05) over the decade. Despite the deterioration in the clinical profile of the patient undergoing coronary bypass surgery, elective procedures were still performed with low mortality. The significant increase in overall mortality was chiefly in patients undergoing emergency operation (p less than 0.05). There were also increases in operative morbidity including low output syndrome (p less than 0.01) and respiratory (p less than 0.005) and neurologic (p = 0.06) complications.
Age Factors↗