Cardiac denervation after transmyocardial laser.
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Angina Pectoris↗
Biomedical subjects
R R Lazzara
Publications and source records attributed to R R Lazzara.
A new technique for intraoperative graft angiography utilizing the radial artery stump.
BACKGROUND: Angiographic visualization is the gold standard in evaluating the patency of newly constructed bypass grafts. With the growth of beating heart bypass grafting procedures, there is a need to confirm patency and document the success of the operative techniques. METHODS: We have developed a new technique for performing intraoperative graft angiography following off-pump coronary artery bypass grafting (OPCABG) when utilizing the left radial artery as a free graft. Once the radial artery is removed, the proximal radial artery stump is cannulated using a standard femoral introducer sheath passed over an appropriately sized guide wire. The introducer is secured by simple ligature and the arm remains abducted during the construction of the grafts. Prior to heparin reversal, standard coronary angiographic catheters are introduced through the sheath and intraoperative images of the grafts obtained. RESULTS: Transsternal OPCAB was performed in 7 patients using the left radial artery as a free graft followed by transradial artery completion angiography. A total of 18 grafts (2.5 per patient) were examined with an immediate patency rate of 100% and TIMI grade 3 flow in all grafts. Mean fluoroscopy time was 8.21 minutes. No angiographic or surgical complications occurred in this group. CONCLUSIONS: Beating heart coronary bypass grafting is evolving as a new standard that competes with the traditional technique of cardiopulmonary bypass and elective cardiac arrest. With newer digital portable fluoroscopy systems, excellent imaging of newly constructed grafts can be obtained prior to completion of the procedure using a transradial approach. Verification of graft patency is the essential element in protecting the quality of surgical coronary artery reconstruction in the new era of beating heart surgery.
Aged↗
Minimally invasive direct coronary bypass versus cardiopulmonary technique: angiographic comparison.
BACKGROUND: Studies comparing minimally invasive direct coronary artery bypass grafting (MIDCABG) with techniques using cardiopulmonary bypass (CPB) are needed. METHODS: Sixteen patients underwent single-vessel left internal thoracic artery-left anterior descending (LITA-LAD) MIDCABG through a left anterior thoracotomy, and 10 underwent multivessel bypass grafting that included a LITA-LAD, using CPB. Intraoperative completion angiography was performed on all LITA-LAD bypasses, and graded. One point each was given for: anastomotic patency, pedicle patency, intercostal obliteration, proper placement into the correct native coronary artery, and Thrombosis In Myocardial Ischemia grade III flow. RESULTS: There were no intraoperative deaths or morbidities. LITA takedown averaged 49 +/- 18.6 minutes for MIDCABG and 16 +/- 2.0 minutes for CPB CABG (p < 0.05). LITA length did not differ between groups (15.3 +/- 1.2 cm for MIDCABG, 14.3 +/- 1.08 cm for CPB CABG). Ischemic arrest time was significantly less for the CPB group (13.3 +/- 8.3 minutes versus 24.5 +/- 9.6 minutes; p < 0.05). Average grade for MIDCABG LITA-LAD was 4.06 +/- 0.98 points versus 4.77 +/- 0.98 points for CPB LITA-LAD bypass (p = not significant). CONCLUSIONS: Intraoperative completion angiography is feasible and, when combined with a grading system, may facilitate the comparison of MIDCABG with standard techniques.
Aged↗
Right parasternal incision: a uniform minimally invasive approach for valve operations.
The right parasternal incision can be used for replacing or repairing cardiac valves. A specialized retractor system produces excellent exposure and helps avoid groin cannulation. The approach reduces surgical dissection and trauma, does not require sacrifice of mammary arteries, prevents rib spreading, avoids sternotomy, reduces the risk of cardiac injury at subsequent redo operations, and does not require specialized video or thoracoscopic equipment.
Adult↗
Reduction in costs, blood products, and operating time in patients undergoing open heart surgery.
OBJECTIVE: To test the hypothesis that use of aprotinin at hall dose would be more cost-effective or as efficacious as full-dose aprotinin or no aprotinin during open heart surgery. DESIGN: Cost-effective analysis, unmasked prospective comparison. SETTING: Community hospital. PATIENTS: One hundred thirty-three patients undergoing open heart surgery. INTERVENTIONS: Patients in 3 consecutive groups undergoing open heart surgery were allocated to receive no aprotinin, full-dose aprotinin, or half-dose aprotinin. MAIN OUTCOME MEASURES: Total cost (in dollars) of blood products administered plus cost of aprotinin at various dosages, comparison of total blood products administered during hospitalization, and closure time required in the operating room. RESULTS: Full-dose and half-dose aprotinin significantly (P < .05) reduced the total blood products administered during hospitalization and the operating room closure time. However, use of half-dose aprotinin resulted in a significant cost savings (P < .05) when compared with either the cost of blood products required in the nodose aprotinin group or the cost of blood products plus aprotinin in the full-dose aprotinin group. CONCLUSION: Use of aprotinin at half dose in a community hospital resulted in a significant reduction in costs, blood product use, and operating room closure time in patients undergoing open heart surgery.
Aged↗
Repair of congenital pulmonary incompetence by bicuspidization of the pulmonary valve.
We report the successful repair of pulmonary incompetence in an adult due to the congenital absence of the posterior leaflet of the pulmonary valve. The repair consisted of bicuspidization of the pulmonary valve, which achieved competence and eliminated the symptoms and echocardiographic manifestations of right ventricular overload while preserving the native valve.
Female↗
Intraoperative angiography during minimally invasive direct coronary artery bypass operations.
BACKGROUND: The technical demands of beating heart operations raise concerns about anastomotic patency. This feasibility study tested the usefulness of intraoperative angiography during minimally invasive direct coronary artery bypass grafting (MIDCABG). METHODS: Ten patients underwent intraoperative angiography of the internal thoracic artery (ITA) after MIDCABG. Minimally invasive direct coronary artery bypass grafting was performed on a beating heart through the fourth or fifth intercostal space. Angiography was performed through the right or left femoral artery with a 7F introducer system placed before the operation. Views were obtained in the right and left anterior oblique and straight anterior projections. RESULTS: There were no deaths or intraoperative morbidities related to MIDCABG or angiography. Seven patients demonstrated widely patent MIDCABG anastomoses with obliteration of all intercostals, widely patent ITA pedicles, good distal runoff, and placement of the ITA into the proper native coronary artery. Two patients had revisions of their ITA pedicles, which on repeated angiography showed correction. One patient's procedure was converted to a sternotomy because of poor distal runoff and haziness at the level of the MIDCABG anastomosis. CONCLUSIONS: This feasibility study demonstrates the utility of intraoperative ITA angiography in identifying problems after MIDCABG. Intraoperative angiography may facilitate MIDCABG by documenting proper placement of conduits, obliteration of intercostal vessels, and patency of the MIDCABG anastomosis and ITA pedicle.
Aged↗
Cardiac tamponade following minimally invasive direct coronary artery bypass.
We report a case of cardiac tamponade resulting in a death following minimally invasive direct coronary artery bypass. Despite absence of clinical symptoms at the time of hospital discharge, cardiac tamponade physiology may have been evident on close evaluation of Doppler studies of the left internal mammary artery. Performance of a predischarge transthoracic echocardiogram may have been confirmatory and lifesaving.
Cardiac Tamponade↗
Extracorporeal membrane oxygenation: preliminary results in patients with postcardiotomy cardiogenic shock.
Long-term survival at our institution for postcardiotomy cardiogenic shock patients supported with the BioPump is 36% (29/80 patients). A heparin-coated extracorporeal membrane oxygenator (ECMO), first introduced in 1991, may reduce organ injury associated with cardiopulmonary bypass. The device can be employed rapidly because it connects directly to the cardiopulmonary bypass cannula. In an effort to improve our results in the treatment of postcardiotomy cardiogenic shock, we used ECMO in 21 patients with this syndrome and accompanying complications. The patients were divided into three groups: group 1, ECMO after coronary artery bypass grafting; group 2, ECMO after mitral valve operation; and group 3, ECMO after open heart operation with prolonged cardiac arrest. Survival in group 1 was 80% with 12 of 14 patients discharged to home. All three deaths were caused by cardiac failure. Bleeding complications in this group were moderate. There was no evidence of disseminated intravascular coagulation, and levels of fibrin split products remained within the normal range. Postoperative complications included stroke (2), renal failure (1), mediastinitis (1), and prolonged respiratory failure (6). Mortality in group 2 was 100%. The major problem limiting recovery was left ventricular distention secondary to inadequate left ventricular decompression. Mortality in group 3 was 100%; all 4 died of brain death. Extracorporeal membrane oxygenation without left ventricular drainage clearly is not effective in patients undergoing mitral valve operations as it does not effectively decompress the left ventricle, but it was highly effective in treating postcardiotomy cardiogenic shock in our coronary artery bypass grafting patients. Extracorporeal membrane oxygenation also proved to be safe as the patient-related complications of stroke, renal failure, and mediastinitis were low. Our preliminary success with heparin-coated ECMO now needs to be confirmed by studies from other centers with larger groups of patients.
Adult↗
Autogenous cardiac assist with chronic descending thoracic aortomyoplasty.
Alternative surgical treatments to orthotopic cardiac transplantation are needed for patients with heart failure. We hypothesized that descending thoracic aortomyoplasty with conditioned (fatigue-resistant) latissimus dorsi muscle could provide diastolic augmentation that would improve left ventricular function. Six mongrel dogs were studied. The left latissimus dorsi muscle was wrapped clockwise around the descending thoracic aorta. Left ventricular volume was measured with a conductance catheter. Aortic and left ventricular pressures were measured with a micromanometer. The following were measured after descending thoracic aortomyoplasty at baseline and with the descending thoracic aortomyoplasty stimulated 1:1 with the heart rate: stroke work, stroke volume, left ventricular peak pressure, maximum rate of increase of left ventricular pressure, diastolic relaxation time constant, peak rate of pressure decay, left ventricular end-diastolic pressure, endocardial viability ratio, mean diastolic aortic pressure, peak diastolic aortic pressure, and time-averaged aortic diastolic velocity. Before data collection, the latissimus dorsi was stimulated (5 pulses delivered at 33 Hz at a rate of 28 per minute for 4 weeks) with burst stimulation to induce fatigue resistance. Results (expressed as the mean +/- the standard error of the mean) showed significant improvement in the indices of ventricular contractility (maximum rate of increase of left ventricular pressure, 1,217 +/- 83 to 1,414 +/- 91 mm Hg/s) and diastolic relaxation mechanics (peak rate of pressure decay, 1,152 +/- 92 to 1,282 +/- 79 mm Hg/s; diastolic relaxation time constant, 43 +/- 2 to 38 +/- 2 ms). Significant differences were noted with stimulation at 1:1 in the endocardial viability ratio (0.90 +/- 0.05 to 1.14 +/- 0.04), an index of myocardial oxygen supply. Systemic diastolic pressures (peak diastolic aortic pressure, 95 +/- 6 to 107 +/- 5 mm Hg; mean diastolic aortic pressure, 92 +/- 6 to 102 +/- 6 mm Hg) and the time-averaged aortic diastolic velocity (1.5 +/- 0.6 to 3.3 +/- 1.0 m/s) increased significantly. We conclude that descending thoracic aortomyoplasty stimulation with conditioned latissimus dorsi muscle can improve indices of ventricular contractility, diastolic relaxation mechanics, diastolic pressures, and diastolic aortic velocity in the nonfailed canine heart. Further studies with the chronic failed heart model are required.
Animals↗
Dynamic descending thoracic aortomyoplasty: comparison with intraaortic balloon pump in a model of heart failure.
Descending thoracic aortomyoplasty (DTA) uses the latissimus dorsi muscle to compress the proximal descending thoracic aorta as an autogenous diastolic counterpulsator. We studied the hypothesis that DTA could confer hemodynamic benefits equivalent to those yielded by an intraaortic balloon pump (IABP) in dogs (n = 7) with heart failure. The left latissimus dorsi muscle was wrapped around the proximal thoracic aorta and subsequently electrically conditioned to induce fatigue resistance. Heart failure was produced by rapid ventricular pacing after muscle conditioning. Data were collected under three conditions: (1) after the induction of heart failure; (2) with the 20-mL IABP at 1:1; and (3) with the DTA stimulated at 1:1. Effective diastolic counterpulsation was achieved with both the IABP and the DTA. The mean diastolic aortic pressure increased from 66 +/- 5 mm Hg at baseline to 90 +/- 4 mm Hg with the IABP and to 75 +/- 4 mm Hg with the DTA. The left ventricular peak and end-diastolic pressures decreased with IABP (95 +/- 5 mm Hg versus 88 +/- 4 mm Hg and 16 +/- 4 mm Hg versus 12 +/- 4 mm Hg, respectively; p < 0.05) and with DTA (95 +/- 5 mm Hg versus 87 +/- 4 mm Hg and 16 +/- 4 mm Hg versus 12 +/- 4 mm Hg, respectively; p < 0.05). Counterpulsation with the IABP did not change the end-systolic pressure-volume relationship or the time constant for diastolic relaxation, whereas the DTA increased the end-systolic pressure-volume relationship (3.2 +/- 0.6 mm Hg/mL versus 4.0 +/- 0.7 mm Hg/mL; p < 0.05) and decreased the time constant for diastolic relaxation (49 +/- 5 msec versus 45 +/- 6 msec; p < 0.05). These data show that DTA using conditioned skeletal muscle can provide diastolic counterpulsation in animals with compromised cardiac function.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Experimental studies on heterotopic lung transplantation during temporary pulmonary insufficiency.
Survival from reversible forms of severe pulmonary insufficiency remains dismal despite the development of artificial oxygenators. We hypothesized that an intraabdominal heterotopic lung could help maintain adequate oxygenation during acute pulmonary insufficiency. Five mongrel dogs underwent an acute heterotopic lung transplant (HLT). The left atrial cuff was anastomosed to the inferior vena cava, and the left pulmonary artery was anastomosed to the abdominal aorta. The trachea was exteriorized, intubated, and ventilated with a volume-controlled ventilator. Ventilation to the native lungs was discontinued. The heterotopic lung was then ventilated at a rate of 20/min, tidal volume of 15 ml/kg, and inspired concentration (FIO2) of 50 percent. Partial pressure of oxygen (PO2) and mixed venous oxygen saturation (SvO2) were maintained at 53 +/- 5.2 mm Hg and 71 +/- 12 percent, respectively. Flow through the HLT was approximately 20 percent of the systemic cardiac output and did not vary with changes in FIO2, respiratory rate, or positive end-expiratory pressure (PEEP). Four separate animals underwent HLT and were studied 2 to 3 days later. The FIO2 was reduced in the native lungs to 10 percent until SaO2 was less than 90 percent. The HLT was then ventilated at a tidal volume of 300 ml, an FIO2 of 50 percent, and a respiratory rate of 10. Arterial PO2 increased from 62 +/- 4 mm Hg to 75 +/- 2 mm Hg, and SvO2 increased from 75 +/- 2 percent to 82 +/- 3 percent (p < 0.05). Flow through the HLT increased slightly to 27 percent of the systemic cardiac output. We conclude that a HLT can augment oxygenation after induction of moderate hypoxemia, but cannot serve as the sole source for gas exchange because flow through the HLT is limited to less than 30 percent of the cardiac output.
Abdomen↗
Right latissimus dorsi cardiomyoplasty augments left ventricular systolic performance.
We hypothesized that the right latissimus dorsi cardiomyoplasty augments left ventricular performance. Five dogs underwent staged right latissimus dorsi cardiomyoplasty. Ventricular function was studied 1 to 3 weeks later. Left ventricular pressure was measured with a micromanometer and left ventricular dimensions with piezoelectric crystals. Inferior vena caval occlusion was used to vary preload. Pressure-volume data were collected with the muscle unstimulated and stimulated at 1:2 and 1:1 muscle/heart ratios. The end-systolic pressure-volume relation (mm Hg/mL), stroke work, preload recruitable stroke work, left ventricular end-diastolic volume, and the diastolic relaxation constant were calculated and expressed as mean +/- standard deviation. Stimulated beats at a 1:2 ratio showed an increase in stroke work of 42.1% (978 +/- 381 to 1,390 +/- 449 g.cm; p < 0.01) and preload recruitable stroke work of 28.8% (59.4 +/- 20.7 to 76.6 +/- 11.0 g.cm/cm3; p = 0.05) compared with the unstimulated beats. With the stimulator on at 1:1, smaller changes occurred: stroke work increased 9% (1,167 +/- 390 to 1,273 +/- 363 g.cm; not significant) and preload recruitable stroke work increased 27% (63.9 +/- 22.7 to 80.9 +/- 23.1 g.cm/cm3; p = 0.05). There were no significant changes in the end-systolic pressure-volume relation. The diastolic relaxation constant did not change at 1:1 (36 +/- 9.7 to 37 +/- 6.4 ms; not significant) or 1:2 (36 +/- 9.3 to 39 +/- 8.2 ms; not significant). Left ventricular end-diastolic volume was unchanged at 1:1 (34 +/- 10.7 to 32 +/- 10.3 mL) and at 1:2 (31 +/- 9.0 to 32 +/- 8.7 mL).(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Metoclopramide-induced tardive dyskinesia: a case report.
A case of tardive dyskinesia developed in a patient who had been treated with metoclopramide for 8 months. Acute extrapyramidal side effects are also possible with this medication. Guidelines for the use of metoclopramide are presented with special emphasis on patients with renal insufficiency and the elderly. The importance of consultation-liaison psychiatrists' familiarity with the neurologic side effects of this commonly prescribed drug used in general medical practice is emphasized.
Aged↗
Extracorporeal membrane oxygenation for adult post cardiotomy cardiogenic shock using a heparin bonded system.
Extracorporeal membrane oxygenation (ECMO) for adult post cardiotomy cardiogenic shock has had limited success. The efficacy of a heparin bonded ECMO system was tested in 11 patients (eight men, three women; mean age: 63 +/- 8 years), all of whom were in post cardiotomy shock refractory to inotropes and intra-aortic balloon pumping (IABP). The system consisted of a right atrial-to-aortic loop using a hollow fiber oxygenator driven by a vortex pump. All blood contact surfaces were heparin bonded. Mean duration of support was 47.9 hr (range: 22-92.5 hr). Mean prothrombin time, activated partial thromboplastin time, and activated clotting time during full support were 17 +/- 8, 57.5 +/- 38, and 152 +/- 59 sec, respectively. Mean transfusion requirements for packed red blood cells, fresh frozen plasma, and platelets were 24 +/- 9, 19 +/- 9, and 38 +/- 15 units, respectively. Complications included acute renal failure (1 patient), sepsis (3 patients), elevation of hepatic enzymes (7 patients), and myocardial infarction (11 patients). Oxygenator failure occurred in 4 patients, and 10 patients had plasma hemoglobin levels exceeding 30 mg/L. No patient experienced focal neurologic deficit. Eight (73%) patients were weaned from ECMO. Five (45.4%) of these are alive and have been discharged home with a mean follow-up of 317 +/- 76 days (range: 179-416 days). This heparin-free ECMO system allows rapid and simple deployment and provides effective short-term cardiopulmonary support.
Adult↗
Cardiac myxomas: results of surgical treatment.
Nineteen patients with cardiac myxoma were seen at Allegheny General Hospital from November 1974 to December 1990. Eighteen underwent operative removal, 9 females and 9 males; age range was 29-81 (mean 55). There were 18 operations for removal of a total of 24 myxomas. Fifteen patients had single myxomas and 3 had multiple myxomas. Of the 3 patients with multiple myxomas, 2 were familial. One patient had a metastatic recurrence intracranially. Perioperative mortality was 1 of 18 (5.5%). Operative morbidity was 12 of 18 (66.6%). Three patients required permanent pacemakers postoperatively (16.6%). Follow-up is complete and 15 of 17 patients (88%) are alive at a mean follow-up interval of 66.6 months (range 3-196 months).
Female↗
Heterotopic lung transplantation: temporary biologic support for reversible pulmonary insufficiency.
BACKGROUND: The mortality rate resulting from adult respiratory distress syndrome in patients awaiting orthotopic lung transplantation remains high. Providing an "extra" lung may provide a potential solution to support a failing pulmonary system. We hypothesized that using a heterotopic lung transplant can correct hypoxemia and hypercarbia in both the short term and the long term. METHODS: Seven mongrel dogs underwent transplantation of a left lung into the abdomen. Anastomosis between the left atrial cuff and the pulmonary artery of the donor lungs was accomplished to systemic venous and arterial circulations, respectively. The main stem bronchus was exteriorized, intubated, and ventilated. Immunosuppression consisted of prednisone and azathioprine both preoperatively and postoperatively. Progressive levels of systemic hypoxemia and hypercarbia were induced. The heterotopic lung transplant augmented oxygenation with a tidal volume of 300 cc, a fraction of inspired oxygen of 50%, and a respiratory rate of 10 and then 20 breaths/min. Four animals were studied again at 48 hours. Flow through the heterotopic lung transplant ranged from 25% to 33% of the cardiac output. RESULTS: Statistically significant improvements were seen in both systemic oxygenation and ventilation in the short-term experiment. The systemic oxygen pressure improved from 37 +/- 3 mm Hg to 67 +/- 5 mm Hg after ventilation of the heterotopic lung transplant, and the carbon dioxide pressure improved from 56 +/- 1 mm Hg to 43 +/- 2 mm Hg. At 48 hours an improvement in oxygen pressure was noted after ventilation of the heterotopic lung transplant, from 42 +/- 3 mm Hg to 56 +/- 2 mm Hg and an improvement in systemic carbon dioxide pressure was noted after ventilation of the heterotopic lung transplant from 57 +/- 7 mm Hg to 46 +/- 4 mm Hg. CONCLUSIONS: The heterotopic lung transplant was able to provide effective gas exchange and support both oxygenation and ventilation after the induction of acute hypoxemia or hypercarbia, both immediately and at 48 hours after implantation. The heterotopic lung transplant may serve as an alternative mode of temporary support for those with acute respiratory insufficiency or as a bridge for those awaiting orthotopic lung transplantation.
Abdomen↗
Chronic counterpulsation with descending thoracic aortomyoplasty improved cardiac function in animals with heart failure.
Descending thoracic aortomyoplasty uses latissimus dorsi muscle for extraaortic diastolic counterpulsation. We hypothesized that descending thoracic aortomyoplasty could improve ventricular function in dogs (n = 5) with heart failure. The left latissimus dorsi muscle was wrapped around the descending aorta and conditioned for 4 weeks with a burst stimulator (five pulses, 33 Hz, 28 bursts/min). Heart failure was induced by rapid ventricular pacing after conditioning. Left ventricular volume was measured with a conductance catheter. Left ventricular and aortic pressures were measured with a micromanometer. Mean diastolic blood pressure, endocardial viability ratio, left ventricular peak pressure, left ventricular end-diastolic pressure, stroke work, isovolumic relaxation time constant, and the end-systolic pressure volume relation were measured at baseline (after heart failure) and with the descending thoracic aortomyoplasty stimulated at 1:1. Contraction of the descending thoracic aortomyoplasty augmented mean diastolic blood pressure (62 +/- 4 to 71 +/- 3 mm Hg) and endocardial viability ratio (1.0 +/- 0.30 to 1.5 +/- 0.13) (p < 0.05). Left ventricular peak pressure (98 +/- 4 to 88 +/- 3 mm Hg), left ventricular end-diastolic pressure (19 +/- 4 to 14 +/- 4 mm Hg), and stroke work (1048 +/- 124 to 743 +/- 80 mm Hg.cm3) (p < 0.05) were reduced. The end-systolic pressure volume relation increased with descending thoracic aortomyoplasty stimulation (3.7 +/- 0.7 to 4.5 +/- 0.8 mm Hg/mL), and the isovolumic diastolic relaxation time constant significantly decreased (54 +/- 6 to 49 +/- 7 msec) (p < 0.05). We conclude that descending thoracic aortomyoplasty can provide diastolic counterpulsation and reduce stroke work in animals with heart failure.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗