Biomedical subjects
Publications and source records attributed to Ehud Raanani.
We herein describe four modifications of graft construction in coronary bypass surgery, including composite left mammary arterial T graft, arterial-venous I, and U grafts, and coronary-coronary vein graft and discuss their indications.
Takayasu arteritis (TA) is an inflammatory arteritis involving large vessels, predominantly the aorta and its main branches. Angina pectoris or myocardial infarction may occur in 3-5% of patients. Symptomatic coronary artery disease may be in rare case the first sign of TA. We describe a case of a young woman in whom acute myocardial infarction and cardiogenic shock and stroke were the initial presentations of TA.
Early extubation after isolated coronary artery bypass surgery was assessed retrospectively in 545 of 779 patients treated by the same surgical team over one year. All underwent extubation within 10 hr of arrival at the cardiothoracic intensive care unit: 343 in < 6 hr and 202 in 6-10 hr. Operative mortality was 2.2%. Group comparisons revealed that patients who had earlier extubation were younger (61 vs. 66 years; p < 0.001), more likely to be male (72.5% vs. 61.3%; p < 0.05), with a shorter aortic crossclamp time (49.2 +/- 15.0 vs. 53.3 +/- 14.0 min; p < 0.05), cardiopulmonary bypass time (65 +/- 18.4 vs. 72.2 +/- 19.2 min; p < 0.05), intensive care unit stay (18.8 +/- 5.6 vs. 22.4 +/- 3.2 hr; p < 0.05) and postoperative hospital stay (5.2 +/- 2.2 vs. 6.0 +/- 2.4 days; p = 0.01). Extubation < 6 hr after cardiopulmonary bypass may accelerate recovery. The finding of no significant differences in clinical parameters between the groups suggests that efforts to further reduce the time to extubation might be worthwhile.
BACKGROUND AND AIM OF THE STUDY: Although the use of new sources of energy for the ablation of atrial fibrillation (AF) has simplified the procedure, concerns have been expressed with regard to the safety and efficacy of the various devices. Herein are described the results of a technique using a combination of bipolar radiofrequency (RF) and cryoablation. METHODS: Between February 2004 and August 2005, the combined procedure was used on 60 patients, 32 of whom (54%) had persistent AF, and 28 (46%) permanent AF. Lesions set similar to the Maze III procedure were used, with the addition of a right atrial isthmus lesion in the area of the coronary sinus and without right atrial appendage amputation and septal lesion. RESULTS: There were no operative complications and no death or major morbidity. The mean duration of the ablation procedure was 30 min (range: 27-36 min) for biatrial procedures, and 16 min (range: 15-19 min) for left atrial procedures. Forty-two patients (70%) were discharged in sinus rhythm. On completion of follow up, 48 patients (80%) were in sinus rhythm. Among 45 patients treated with cryoablation rather than monopolar RF, 89% were in sinus rhythm at the mean follow up of nine months. The predictor for recurrent post-procedural AF was preoperative permanent AF for more than 10 years' duration (p = 0.039), while that for postoperative atypical flutter was use of the monopolar RF ablator rather than the cryoablator (p = 0.001). CONCLUSION: The use of a bipolar RF device with the cryoprobe is an appealing combination which enables the Maze III lesion set to be completed in a straightforward, safe, and efficient manner.
BACKGROUND: Left atrial radiofrequency ablation is the most common technique for the treatment of atrial fibrillation during mitral valve surgery. Reported failure rates range between 15% and 30%, with some patients remaining in atrial fibrillation and others experiencing atrial flutter. The incidence and nature of the postoperative atrial flutter is not yet well defined. METHODS: The study group consisted of 50 patients with atrial fibrillation who underwent mitral valve surgery combined with left atrial radiofrequency ablation, and were followed for a mean period of 15 +/- 7 months. The majority of patients (39; 78%) had persistent or permanent atrial fibrillation. Placement of the ablation lines was as follows: encircling the pulmonary veins, isolating the base of the left atrial appendage, and bridging the lateral or posterior mitral annulus and the margin of the pulmonary vein or the appendage-encircling ablation lines. RESULTS: There were three hospital deaths (6%). Thirty-four (72%) patients were free of any atrial tachyarrhythmia events, and 37 (79%) patients were in sinus rhythm by the end of the study's follow-up. During the follow-up, 6 patients (12.7%) experienced atrial flutter and 1 patient had atrial tachycardia. Electrophysiologic study was performed in 5 of 6 patients with postoperative atrial flutter. In 4 of them, the study findings were consistent with left atrial flutter. One patient with typical isthmus-dependent right atrial flutter underwent successful ablation. CONCLUSIONS: Left atrial surgical radiofrequency ablation is associated with a high rate of postoperative atrial flutters that appear to be predominantly of left-sided origin.
A 48-year-old man undergoing orthotopic heart transplantation for ischemic cardiomyopathy developed severe right heart failure. Severe intractable bleeding complicated implantation of a right ventricular assist device. Treatment with 9.6 mg of recombinant activated factor VII stopped the bleeding, and the patient could be transferred to the intensive care unit. This is the first reported case of the successful use of recombinant activated factor VII to control bleeding with subsequent right ventricular assist device function.
Infective endocarditis is a disease with various presentations and conditions, so that the medical team faces many dilemmas, mainly on indications and timing for surgical intervention. The results of surgery depend upon many factors: the general preoperative condition of the patient, antibiotic treatment, timing of surgery, perioperative management, surgical techniques, postoperative management and follow-up. Optimal diagnosis and management of patients with infective endocarditis requires clinical judgment based on extensive experience. In spite of the current best practices and guidelines for surgical interventions in infective endocarditis, we face patients that do not "fall directly" into the obvious guidelines. This editorial covers some of the topics that remain controversial: timing for surgical interventions, selection of prosthetic valve type, technical aspects regarding complex infective endocarditis, and ethical decisions.
BACKGROUND: The role of intraoperative transesophageal echocardiography (IOTEE) in valve replacement surgery is not well established. The aim of this study was to explore the impact of immediate postpump IOTEE in valve replacement surgery at a single tertiary medical center. METHODS: The departmental database was screened for valve replacement operations (mechanical or bioprosthetic valves) performed during a 55-month period that were succeeded by immediate postpump IOTEE. Data was gathered regarding the impact of IOTEE on the immediate postoperative course. RESULTS: The study group included 417 patients (44.8% male, 55.2% female, age 65.2 +/- 13.9 years). Prepump IOTEE was performed in 352 patients (84.4%). A single valve was replaced in 336 patients (80.6%) and two or more valves were replaced in 81 patients (19.4%). Overall 501 valves were inserted: mitral, 237 (131 mechanical, 106 biological); aortic, 221 (89 mechanical, 132 biological); tricuspid, 43 (2 mechanical, 41 biological). Unexpected pathologic echocardiographic findings on postpump IOTEE necessitated immediate surgical correction in 15 patients (3.6%): perivalvular leak in 8 patients (4 mitral, 4 aortic), immobilized leaflet in 4 patients (3 mitral, 1 tricuspid), coronary obstruction by an aortic bioprosthesis in 2 patients, and incompetent xenograft in 1 patient. Prolonged removal of air was necessary in 45 patients (10.8%). In 47 patients (11.3%) the postpump IOTEE contributed to the evaluation of difficult weaning from the bypass pump and to its appropriate therapeutic management (volume expansion, inotropic agents, vasodilators, or mechanical assistance). CONCLUSIONS: Immediate postpump IOTEE is an important diagnostic and therapeutic role in valve replacement surgery and should be widely implemented.
BACKGROUND: Isolated stenosis of the left main coronary artery is usually treated by coronary bypass surgery. However, this approach restores a less physiologic perfusion of the myocardium that leads to occlusion of the left main coronary artery, and restores only a retrograde perfusion of a rather extensive myocardial area. Coronary ostial plasty has been described as an alternative surgical technique in isolated ostial left main coronary artery stenosis without calcification. We review our experience with 15 patients. METHODS: After placing the patient on cardiopulmonary bypass and aortic cross clamping, the main pulmonary trunk was retracted laterally. The left main coronary artery was approached anteriorly through a curved aortotomy. Reconstruction was performed using fresh pericardial patch or saphenous vein that was tailored as a patch. RESULTS: There were no early mortality or perioperative myocardial infarctions. During mean follow-up of 55 +/- 39 months, no patients had any cardiac events or required repeated coronary intervention. All patients underwent follow-up transesophageal echocardiography, which demonstrated a wide open left main coronary artery (range 3 to 8 mm), normal flow pattern by pulsed-wave Doppler, and no aneurysmal dilatation or calcification of the onlay patch. Coronary angiography and intravascular ultrasound were performed in 2 patients because of nonspecific chest discomfort. In both cases, the left main coronary artery was found to be wide open, and there were no signs of patch calcification. CONCLUSIONS: Surgical reconstruction of the left main coronary artery is safe and effective for the treatment of selected cases of isolated left main stenosis. The use of autologous pericardium appears to be as safe as saphenous vein patch. Neither method was associated with postoperative aneurysmal dilatation or calcification.
BACKGROUND: Reports from Europe and North America indicate that significant changes have occurred in the practice of cardiac surgery in the last two decades. OBJECTIVES: To examine the trends and case-mix in cardiac surgery in Israel and their relationship with changes in invasive cardiology. METHODS: We analysed data collected by the Ministry of Health from all cardiac centers in Israel from 1985 to 2002. RESULTS: Three periods were identified: the 1980s, when a relatively small number of operations were performed; 1990-1994, characterized by a dramatic rise in the number of operations; and 1994-present, characterized by a small decline and stabilization in the rate of operations. The percentage of valve procedures increased significantly from 15% of all cardiac surgeries in 1991 to 21% in 2002 (P = 0.002). In addition, the chance of a diagnostic coronary angiography being followed, in the same patient, by an interventional procedure such as percutaneous transluminal coronary angioplasty or by a coronary artery bypass graft increased dramatically from 42% in 1991 to 69% in 2002. At Rabin Medical Center, there was a constant decline in the percent of repeated CABGs out of the total CABGs performed, from 6.7% in 1996 to 1.3% in 2002. CONCLUSIONS: Despite the rise in the rate of percutaneous coronary interventions since 1991, there has been no significant decline in the rate of CABGs performed. However, there is a significant shift to more complex operations. The number of repeated CABG operations has significantly decreased and, in view of the growing use of arterial grafts and further improvements in invasive cardiology techniques, we expect this decline to continue.
BACKGROUND AND AIM OF THE STUDY: Concern has been raised regarding the late effects of tissue glues. Herein is described the authors' experience with a new bioadhesive (BioGlue; Cryolife) for repair of the aortic root in acute dissection. METHODS: BioGlue is composed of bovine serum albumin (BSA) and glutaraldehyde. Glutaraldehyde exposure causes the lysine molecules of BSA, extracellular proteins and cell surfaces to bind to each other, creating a strong scaffold. Between January 2001 and January 2003, BioGlue was used to repair the aortic root in 22 patients with acute aortic dissection. Moderate or severe insufficiency was present in 16 cases, and mild insufficiency in six. The mechanism of insufficiency was commissure detachment in 15 cases, penetration of the intimal flap into the valve in three, and dilatation of the sinotubular junction in four. The aortic valve was resuspended to the aortic wall using pledgeted sutures. BioGlue was used to glue the dissected layers of the aortic root and create stronger tissue for sewing. Two patients required complete resection of the sinuses and aortic root remodeling with a Dacron graft. RESULTS: There were two operative deaths. Postoperative transesophageal echocardiography showed mild or no aortic insufficiency in 18 patients, and moderate insufficiency in two. During follow up (mean 16 months), none of the patients required reoperation for proximal redissection, delayed rupture, or aortic insufficiency. CONCLUSION: BioGlue is useful for aortic valve repair in aortic dissection. It is less toxic and has a stronger adhesive effect than the older surgical glues, and is expected to have better long-term results.
BACKGROUND: The introduction of "fast-track" management into cardiac surgery has significantly shortened the intensive care unit (ICU) length of stay. Readmission to the ICU, traditionally used as a quality index, has not been investigated in these patients. The aim of this study was to assess the causes, risk factors, and outcomes associated with readmission to the ICU. METHODS: All patients undergoing open-heart surgery in a tertiary care, university-affiliated center were included in this prospective observational study. Preoperative and intraoperative data as well as ICU outcome were noted in all patients. RESULTS: Over the 27-month study period,1,613 patients were targeted for fast track management (discharge from ICU on the first postoperative day). The readmission rate was 3.29% (53 patients). Forty-three percent of readmissions occurred within 24 hours of discharge usually because of pulmonary problems (43%) or arrhythmias (13%). Readmission was associated with a prolonged ICU stay (105 +/- 180.0 versus 19.2 +/- 2.4 hours of initial ICU stay) and worse outcome: the only patients who died (6 of 53, 11.3%) were in this group. On multivariate analysis, a Bernstein-Parsonnet risk estimate more than 20 strongly predicted readmission (odds ratio, 3.08; 95% confidence interval, 1.43 to 6.69). CONCLUSIONS: Among a homogeneous group of patients targeted for fast-track management after cardiac surgery, readmission although uncommon is associated with a longer second ICU stay and significant mortality. The recognition of specific risk factors may allow for appropriate modification of the postoperative course.
BACKGROUND AND AIM OF THE STUDY: Valvular heart disease, with a propensity for the left valves, is the most important cardiac manifestation of systemic lupus erythematosus (SLE). Libman-Sacks endocarditis complicating SLE has rarely been reported to cause hemodynamically significant valvular lesions necessitating valve replacement. METHODS: This report describes a young woman with moderate aortic regurgitation and moderate to severe mitral regurgitation due to Libman-Sacks endocarditis. RESULTS: Treatment consisted of aortic and mitral valve replacement with mechanical prostheses due to intractable heart failure. The patient's recovery was uneventful. CONCLUSION: A literature survey disclosed only nine reports of double-valve replacement in patients with SLE. These findings, together with the present experience, suggest that valvular disease in SLE changes frequently with time, appears to be temporally unrelated to the other clinical features of SLE, and is associated with substantial morbidity and mortality. Corticosteroid treatment may slow the progression of valvular regurgitation. If surgery is necessary, replacement with a mechanical valve may be better than with a bioprosthesis.
OBJECTIVES: The aim of this study was to investigate the long-term clinical and hemodynamic outcomes after aortic valve replacement with the Carpentier-Edwards Perimount bioprosthesis (Edwards Lifesciences, Irvine, Calif), which has been used in our institution since 1984. METHODS: From January 1984 to December 1995, the Carpentier-Edwards pericardial bioprosthesis was used for aortic valve replacement in 254 patients (male/female ratio 117:137) with a mean age of 71 years (range 25-87 years). Before the operation, 216 patients (85%) were in New York Heart Association functional class III or IV. The predominant diagnosis was aortic stenosis (n = 219, 86%). Associated surgical procedures included coronary artery bypass grafting in 130 cases (51%), mitral valve replacement in 11 cases (4%), and tricuspid or mitral valve repair in 12 cases (5%). Previous cardiac operations had been performed in 36 cases (14%). Follow-up was 100% complete at a mean of 60 +/- 31 months. Univariate estimates of time-related cumulative probabilities were calculated by the Kaplan-Meier method. Multivariable adjustment was performed by Cox proportional hazards regression. Echocardiography was performed in 61% of long-term survivors. RESULTS: There were 11 early deaths (4%) and 58 late deaths. Actuarial survivals at 5, 10, and 12 years were 80% +/- 3%, 50% +/- 8%, and 36% +/- 9%, respectively. At 12 years the freedom from cardiac death was 73% +/- 7%, the freedom from valve-related death was 84% +/- 11%, the freedom from valve reoperation was 83% +/- 9%, the freedom from primary tissue failure was 86% +/- 9%, the freedom from thromboembolism was 67% +/- 13%, and the freedom from endocarditis was 98% +/- 1%. Echocardiography was performed on long-term survivors (mean follow-up 67 +/- 25 months) and showed that transvalvular peak and mean pressure differences measured with Doppler echocardiography were 23.2 +/- 9.6 and 12.3 +/- 4.8 mm Hg, respectively. Aortic regurgitation was found by Doppler echocardiography to be none or trivial, mild, moderate, and severe in 64%, 30%, 3%, and 1% of patients, respectively. Mean left ventricular mass index was 107.2 +/- 35.3 g/m(2) (118.9 +/- 40.2 g/m(2) in men and 98.8 +/- 28.8 g/m(2) in women) at late follow-up. One third of all patients, regardless of sex (n = 26/64 women and n = 14/45 men), had evidence of left ventricular hypertrophy. However, our analyses indicate that the residual left ventricular hypertrophy was not caused by valve mismatch but was probably multifactorial. CONCLUSION: The Carpentier-Edwards Perimount bioprosthesis has provided satisfactory clinical and hemodynamic outcome. However, at long-term follow-up about one third of the patients being investigated still had left ventricular hypertrophy examined by echocardiography.