Severe "silent" mitral regurgitation after myocardial infarction: a clinical conundrum.
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Cardiomyopathies↗
Biomedical subjects
S Westaby
Publications and source records attributed to S Westaby.
Aortico-right ventricular tunnel.
We report successful closure of an aortico-right ventricular tunnel in a 3-month-old infant with heart failure. One-year follow-up shows the child to be developing normally.
Aorta↗
Reoperation for prosthetic valve endocarditis in the third trimester of pregnancy.
A pregnant 29-year-old woman underwent emergency aortic valve re-replacement for prosthetic valve endocarditis. Cesarean section was performed with the chest open ready for cannulation. Fears of uterine hemorrhage during systemic heparinization for cardiopulmonary bypass were unfounded, and both mother and the 28-week-gestation newborn recovered uneventfully.
Adult↗
Hypothermic thoracic and thoracoabdominal aneurysm operation: a central cannulation technique.
Surgical resection of the descending thoracic and thoracoabdominal aorta is associated with the risk of spinal cord ischemic injury, particularly in patients with aortic dissection. Hypothermic total cardiopulmonary bypass with periods of circulatory arrest has been advocated for spinal cord protection with encouraging early results. However, techniques for this procedure are relatively complex. An alternative cannulation technique with venous return from the right atrium through the internal jugular vein and arterial return to the aortic arch is described. This has been used in 6 patients for replacement of the descending thoracic or thoracoabdominal aorta. Despite profound hypothermia and preservation of the principal spinal radicular artery, 1 patient suffered early paraparesis with some recovery but eventually died of multisystem failure. A second elderly patient with severe obstructive airways disease died of respiratory failure 11 days postoperatively. Four patients made a good recovery including 1 with a ruptured thoracoabdominal aneurysm who subsequently required gut resection for ischemic necrosis present preoperatively. This cannulation technique together with profound hypothermia has greatly improved the operating conditions for extensive aneurysms of the thoracoabdominal aorta. Paraparesis occurring despite hypothermic protection and attempted preservation of the spinal cord arterial supply suggests that unfavorable vascular anatomy still predominates in the risk factors for ischemic injury.
Aged↗
Cytokine responses to cardiopulmonary bypass with membrane and bubble oxygenation.
The systemic inflammatory response to cardiopulmonary bypass was assessed in 20 patients who underwent elective coronary artery bypass grafting with flat-sheet membrane oxygenation (group I; n = 10; age, 59 +/- 5 years) or bubble oxygenation (group II; n = 10; age, 62 +/- 8 years). The duration of cardiopulmonary bypass was 46 +/- 12 minutes in group I and 47 +/- 15 minutes in group II. Plasma interleukin-6, plasma interleukin-1 beta, transpulmonary leukocyte counts, pulmonary hemodynamic variables, and respiratory index were determined in all patients perioperatively. The plasma interleukin-6 response (median [range]) was similar in both groups at the end of the operation, peaked 4 hours postoperatively (99 [30 to 320] pg/mL in group I; 123 [21 to 300] pg/mL in group II; p greater than 0.05), and remained elevated 48 hours postoperatively (76 [9 to 140] pg/mL in group I; 65 [25 to 159] pg/mL in group II; p greater than 0.05). No significant interleukin-1 beta response was demonstrated. Pulmonary neutrophil and lymphocyte sequestration was observed on commencement of cardiopulmonary bypass in group II but did not occur in either group on discontinuation of cardiopulmonary bypass. Pulmonary vascular resistance at the end of the operation (82 [48 to 320] dynes.s.cm-5 in group I; 119 [54 to 385] dynes.s.cm-5 in group II; p greater than 0.05) was similar to preoperative values (151 [30 to 327] dynes.s.cm-5 in group I; 185 [62 to 291] dynes.s.cm-5 in group II; p greater than 0.05). The respiratory index at the end of the operation was similarly and significantly increased in both groups (1.26 [0.92 to 4.17] in group I; 1.44 [0.73 to 3.30] in group II).(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Cardiac surgery: moving away from intensive care.
OBJECTIVE: To evaluate outcome in patients managed outside an intensive care unit after open heart surgery. BACKGROUND: The high cost of cardiac surgery is mainly due to the needs of traditional postoperative care. The requirements for intensive care and treatment has decreased with improvements in techniques of cardiac surgery and anaesthesia. In this setting the need to continue to depend on intensive care units for the recovery of cardiac surgical patients is questionable on clinical and economic grounds. DESIGN: Postoperative outcome in 245 patients over a four month period was studied prospectively. PATIENTS: Mean age of the patients was 63.2 years. They underwent a wide variety of operative procedures. Ninety percent of them recovered in a dedicated three bed cardiac surgical recovery area where the management protocol led to rapid extubation and step down in dependency care. RESULTS: Median time for ventilatory support was 90 minutes after transfer to the area. Only five patients were subsequently admitted to the general intensive care unit for prolonged respiratory and cardiac support. Ten patients were electively admitted to the general intensive care unit. Two deaths occurred in hospital in this group (0.8%). Four patients were ventilated for 24 hours in the recovery area itself and made an uncomplicated recovery. CONCLUSION: This study confirms that over 90% of patients undergoing cardiac surgery would recover safely and be treated effectively in a more economical area than intensive care.
Adult↗
Aortic root replacement: modifications of technique with improvements in technology.
Potential morbidity remains substantial in aortic root replacement. The tissues are often fragile, contributing to the risk of haemorrhage and postoperative complications. In the past surgery has been directed towards minimising haemorrhage by wraparound techniques and the right atrial fistula method of Cabrol. However, recent use of aortic homografts, collagen-impregnated grafts and tissue glues have reduced bleeding and simplified operative technique. Profound hypothermia and total circulatory arrest allows aneurysm resection to extend into the aortic arch. Between 1986 and 1991 25 aortic root replacements were carried out at the Oxford Heart Centre in 21- to 76-year-olds, 13 for aorto-annular ectasia (4 due to Marfan's syndrome), 7 for aortic dissection (2 Marfan's syndrome) and 2 for complications of previous aortic valve replacement. Three patients had homograft root replacement for aortic root endocarditis. We implanted 14 Medtronic composite grafts, 1 St Jude conduit and 7 collagen-coated Dacron grafts (Hemashield, Meadox) into which a Starr-Edwards valve was sewn, as well as 3 homografts. One patient with a massive chronic dissection following previous aortic valve replacement required an interposition graft to the coronary ostia. In the others, the coronary ostia were mobilised from the native aorta and directly implanted into the conduit. In dissections a ring of pericardium or GoreTex was used to buttress the coronary anastomoses. Six patients also required coronary artery grafting. Native aorta was excised and not wrapped around the conduit. Coagulation defects were corrected aggressively with platelets, fresh frozen plasma and cryoprecipitate.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Combined cardiac and abdominal aortic aneurysm operations. The dual operation on cardiopulmonary bypass.
Eight patients underwent both cardiac operation and repair of abdominal aortic aneurysm. All had respiratory impairment and significant impairment of left ventricular function, whereas six patients had severe diffuse distal coronary disease. In all patients the cardiac procedure was performed first, and the patients continued to receive cardiopulmonary bypass. Rewarming was not commenced until the abdominal repair was well under way, to protect the vital organs. There were no problems in weaning the patients from bypass, and six of the patients were extubated within 24 hours; one required ventilation for 36 hours. One patient died of colonic infarction complicated by kidney failure without being extubated. Another patient who was initially extubated in 11 hours required reintubation because of poor lung function and eventually died of multisystem organ failure caused by bilateral lower limb ischemia that persisted despite embolectomies. All survivors are well and in New York Heart Association functional class I or II between 3 and 18 months postoperatively. We conclude that for patients considered unfit for abdominal aortic aneurysm operations because of the nature of the cardiac disease, the combined operation with cardiopulmonary bypass is both safe and effective.
Aged↗
Thrombolysis and postinfarction ventricular septal rupture.
We studied all patients with postinfarction ventricular septal rupture referred to the Oxford Heart Centre for operation over a 4 1/2-year period. Twenty one women and 8 men were admitted to the Centre, 13 of whom had received streptokinase and 16 of whom had not. The median interval between symptomatic onset of myocardial infarction and the development of septal rupture was 24 hours for those treated by early thrombolysis (all streptokinase) and six days for those who were not. Of the 26 patients who underwent surgical repair, three were operated on less than 36 hours after streptokinase infusion, in one case within 12 hours of thrombolytic treatment. Macroscopic observation of the disintegrating myocardium showed muscle bundles dissected by blood rendered incoagulable by thrombolytic treatment, together with the histologic features of reperfusion injury. The overall surgical mortality rate for the streptokinase group was 33% and for the others 21%. The patient operated on within 12 hours of thrombolytic treatment recovered uneventfully. Six of seven surgical deaths were caused by left ventricular or biventricular failure and one by gastrointestinal hemorrhage. All survivors were in New York Heart Association classes II or III between 2 weeks and 4 1/2 years after operation. We conclude that thrombolysis leads to early breakdown of the interventricular septum after acute myocardial infarction but does not preclude early repair.
Aged↗
Diaphragm paralysis following cardiac surgery: role of phrenic nerve cold injury.
Diaphragm paralysis has been reported radiologically after cardiac surgery with an incidence ranging from 30% to 75% of patients. We studied 100 consecutive patients undergoing open heart operations, half of whom received ice/slush topical hypothermia (group 1) and half of whom did not (group 2). Chest radiology and diaphragm screening were performed at 1 week, 1 month, and every 6 months thereafter in all patients with an elevated diaphragm. Phrenic nerve conduction time was measured in all patients in whom there was radiological evidence of diaphragm paralysis 1 week postoperatively. The two groups were similar in terms of age and sex. Aortic cross-clamp time was less in group 1 (61.5 +/- 15.6 minutes) compared with group II (74.4 +/- 20.8 minutes), although this difference was not significant. Significant differences, however, were found for radiological evidence of partial left lower lobe collapse (82% in group 1 versus 32% in group 2; p less than 0.01) and for radiological evidence of diaphragm paralysis (32% in group 1 versus 2% in group 2; p less than 0.001) within the first postoperative week. Unilateral diaphragm paralysis developed in 16 group 1 patients (15 left sided, 1 right sided) compared with only 1 patient in group 2. In these 16 group 1 patients, diaphragm paralysis was still present in 12 (75%) at 1 month and in 5 (31.3%) at 1 year postoperatively. There were no significant differences between the two groups in terms of postoperative arrhythmias, myocardial infarction, or mortality. Phrenic nerve conduction time was found to be a sensitive indicator of phrenic nerve cold injury and recovery.(ABSTRACT TRUNCATED AT 250 WORDS)
Cardiac Surgical Procedures↗
Transatrial repair of ventricular septal defect subsequent to myocardial infarction.
We describe successful transatrial repair of a ventricular septal defect occurring secondary to myocardial infarction. This approach avoids the need for ventriculotomy and may be technically simpler and safer than repair across the zone of infarction in a subset of patients with posterior defects and right ventricular dysfunction who survive the early period subsequent to their infarct.
Aged↗
Clinico-radiological correlates in rupture of the major airways.
The plain film appearances of 17 patients with trauma to the major airways were reviewed and correlated with the findings at thoracotomy, bronchoscopy or post-mortem. Predictable radiographic patterns of air leak were discovered which related to the surgical anatomy of the rupture. Airway interruption was seen in two of three patients with laryngeal transection, all showing gross deep and superficial cervico-facial emphysema. Massive mediastinal and deep cervical emphysema without pneumothorax were striking features of tracheal injury. In patients with bronchial rupture all had ipsilateral pneumothorax and most had associated pneumomediastinum, the degree of each component relating to the site of rupture. Only two patients had tension pneumothoraces. These features alone, however, are non-specific and only two of seven patients with bronchial injury showed specific signs of rupture (a fallen lung). An understanding of the mechanisms of injury to the major airways and the predictable resultant patterns of air leak should ensure that such lesions are not overlooked in patients who will usually have sustained multisystem trauma.
Adolescent↗
Bilateral diaphragm paralysis after cardiac surgery with topical hypothermia.
Bilateral diaphragm paralysis is a rare but important complication of open heart surgery. Two cases were found among 360 prospectively studied patients undergoing open heart surgery during one year. Both patients had insulin dependent diabetes with peripheral neuropathy and this may have contributed to their diaphragm paralysis. The patients were studied postoperatively for one year with measurements of lung function, nocturnal oximetry, diaphragmatic function, and phrenic nerve conduction. Treatment with intermittent positive airway pressure ventilation by nasal mask was effective in both patients. After nine months one patient had recovered completely with normal phrenic nerve conduction and diaphragmatic function; the other continues most of his normal daytime activities, but still requires nasal positive airway pressure ventilation for six hours at night.
Cardiac Surgical Procedures↗
Diagnostic delay and outcome in surgery for type A aortic dissection.
Twenty-two patients with acute type A aortic dissection presented to this hospital over a three-year period. The initial diagnosis was incorrect in 12 (54.5 per cent) and in 11 of these the error occurred in peripheral hospitals before referral. This diagnostic mistake lead to a delay in surgical treatment of 2-9 days (median 5 days). Three deaths occurred without surgery, and two of these could have been considered for repair if the correct diagnosis had been made earlier. In the surgically treated group, a 30-day survival of 16 out of 19 (84.2 per cent) was achieved and the three deaths were all related to late referral. Two died because of bowel infarction and one because of respiratory failure. An increased general awareness of acute aortic dissection is necessary as early diagnosis, before the onset of irreversible ischaemic events, allows a high surgical success rate.
Acute Disease↗
ABC of major trauma. Thoracic trauma--II.
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Aortic Rupture↗
ABC of major trauma. Thoracic trauma--I.
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Chest Tubes↗
Streptokinase in acute aortic dissection.
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Acute Disease↗
Trauma centres and the efficient use of financial resources.
The economic aspects of trauma centres were examined using published results and local financial data to discover if such institutions are an efficient use of resources. The cost of trauma centre care depends upon the number of centres built. An 'ideal' system in the UK of eight centres will cost 31.268 pounds per life saved compared with 45.661 pounds for the system proposed by the Royal College of Surgeons of England. Trauma centre care will be expensive but will generate benefits in return. Survivors will be young (mean age 30 years) and most (70-80 per cent) will regain their pre-injury functional/work status. When considered in terms of Quality Adjusted Life Years (QUALYs), trauma centres are a relatively efficient use of resources. An expected cost per QUALY of 942-1376 pounds is inexpensive compared with many health pursuits currently funded within the UK National Health Service.
Cost-Benefit Analysis↗