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We present the case of a primigravid patient, who developed cardiogenic shock during the early postpartum period in the setting of retained placenta, uterine atony, and hemorrhage. Focused cardiac ultrasound played a central role in identifying the cause of hemodynamic instability. The decision to initiate venoarterial extracorporeal membrane oxygenation was instrumental in the successful outcome for our patient, characterized by a full recovery without major neurological and cardiovascular sequelae.

Recently, Israel established the first national-level adult cardiac surgery database, which was linked to the Society of Thoracic Surgeons (STS).To validate and compare the STS predicted risk of mortality (PROM) to logistic EuroSCORE I (LESI) and EuroSCORE II (ESII) in Israeli patients undergoing cardiac surgery.We retrospectively studied 1279 consecutive patients who underwent cardiac surgeries with a calculable PROM. Data were prospectively entered into our database and used to calculate PROM, LESI, and ESII. Scores were normalized and correlated using linear regression and Pearson's test. To examine model calibration, we plotted the total observed versus expected mortality for each score and across five risk-score subgroups. Model discrimination was assessed by measuring the area under the receiver operating curves.The observed 30-day operative mortality was 1.95%. The median (IQ1; IQ3) PROM, LESI, and the ESII scores were 1.45% (0.69; 3.22), 4.54% (2.28; 9.27), and 1.88% (1.18; 3.54), respectively, with observed over expected ratios of 0.63 (95% confidence interval [95%CI] 0.42-0.93), 0.59 (95%CI 0.40-0.87), and 0.24 (95%CI 0.17-0.36), respectively, (STS vs. ESII P = 0.36, STS vs. LESI P = 0.0001). There was good correlation among all scores. All models overestimated mortality. Model discrimination was high and similar for all three scores. Model calibration of the STS, PROM, and ESII were more accurate than the LESI, particularly in higher risk subgroups.All scores overestimated mortality. In Israeli patients, the STS, PROM, and ESII risk-scores were more reliable metrics than LESI, particularly in higher risk patients.

The prosthetic valve of choice in patients with carcinoid valve disease (CVD) remains controversial due to the limited life expectancy of patients with advanced-stage neuroendocrine tumors (NETs) on the one hand, and concerns regarding structural valve deterioration (SVD) on the other hand.The records of 17 patients (11 females, seven males; mean age 65 ± 11 years; undergoing 18 operations) with primarily right heart failure due to CVD were reviewed. All patients received somatostatin analogs perioperatively. Hospital and follow up data (acquired via direct patient contact and echocardiography) collected included baseline characteristics, procedural details, and clinical outcomes.The primary NET site was the ileum (n = 11), lungs (n = 2) and stomach, colon and appendix (n = 1 each). In one patient the primary tumor location could not be identified. Preoperative urinary levels of 5-hydroxyindole acetic acid (5-HIAA; 61 ± 36 mg/24 h) and serum levels of chromogranin A (2926 ± 4057 ng/ml) were 10- and 50-fold greater than normal, respectively. A total of 23 valves was implanted: five tricuspid valve replacements (TVR; four tissue and one mechanical), TVR and pulmonary valve replacements (PVR; three tissue and one mechanical), and TVR and mitral valve replacements (MVR; one tissue and two mechanical). The 30-day mortality was 11% (n = 2). No patient experienced a carcinoid crisis. The mean follow up was 24 ± 21 months (range: 4-85 months). Four patients (receiving seven valves) developed SVD at 12, 14, 15, and 20 months after surgery, and all of these patients died. The actuarial four-year survival and freedom from SVD were 23 ± 14% and 43 ± 15%, respectively.The data acquired suggested that the main advantage of tissue valve prostheses, namely to avoid lifelong, intense anticoagulation, might be offset by accelerated SVD. The use of mechanical valves should be considered in CVD patients with a large primary tumor mass and persistent high urinary levels of 5-HIAA, and who are unresponsive to therapy.

This study documents the gross flow characteristics and capillary distribution of cardioplegic solution delivered retrogradely with the coronary sinus open versus closed. Methods : Five explanted human hearts from transplant recipients were used as experimental models. Hearts served as their own controls and received two doses of warm blood cardioplegic solution, each containing colored microspheres. The first dose was delivered through a retroperfusion catheter with the coronary sinus open and the second dose was delivered with the sinus occluded. Capillary flow was measured at twelve ventricular sites and gross flow was measured by examining coronary sinus regurgitation, thebesian vein drainage, and aortic effluent (nutrient flow). Results : Coronary sinus ostial occlusion allowed for a significant decrease in total cardioplegic flow (1.74 ± 0.40 ml/gm versus 1.06 ± 0.32 ml/gm; p < 0.05) to occur while maintaining an identical intracoronary sinus pressure. Ostial occlusion also resulted in an increase in the ratio of nutrient flow/total cardioplegic flow from 32.3% ± 15.1% to 61.3% ± 7.9% (p < 0.05). A statistically significant improvement in capillary flow was found at the midventricular level in the posterior intraventricular septum and posterolateral right ventricular free wall. This improvement was also documented for the intraventricular septum and right ventricle at the level of the apex. Conclusion : Coronary sinus occlusion during retrograde cardioplegia significantly improves cardioplegic delivery to the right ventricle and posterior intraventricular septum. Furthermore, the technique affords a significant improvement in nutrient cardioplegic flow while reducing the overall volume of cardioplegic solution administered. ( J T HORAC C ARDIOVASC S URG 1995; 109: 941-7)

OBJECTIVES: The management of concomitant coronary and carotid artery disease is still in evolution. The surgical options are staged approach—carotid endarterectomy (CEA), followed by coronary artery bypass grafting (CABG) or a reversed-staged approach, or combined approach—CEA and CABG under the same anaesthesia. In view of the percutaneous carotid artery stenting option, we have reviewed our short- and long-term experience with combined CEA and CABG to define the role of this procedure. METHODS: From January 1992 to December 2006, we operated on 80 patients performing combined carotid endarterctomy and myocardial revascularization. Short- and long-term results were reviewed. RESULTS: Operative mortality was 3.7%. Perioperative cerebrovascular accident (CVA) occurred in 2 patients (2.5%). Perioperative myocardial infarction (MI) occurred in 3 patients (3.7%). Combined complications of death + MI + CVA = 10%. During the mean follow-up of 10 ± 3.2 years (1–14 years), 6 patients (7.6%) had neurological events. Freedom from neurological events for 10 years was 92 ± 4%. Nearly 17 (21.5%) had cardiac events. The 5-year and 10-year survival rates were 74 ± 5 and 62 ± 6%, respectively. CONCLUSIONS: Although the short-term results of the non-surgical carotid therapeutic alternative is similar to our surgical results, there are limitations to carotid artery stenting: the need for aggressive antiplatelets therapy, and the haemodynamic changes during the procedure that may be unacceptable for patients with unstable coronary artery disease. Therefore, there is still a role for concomitant surgical CEA and CABG to the results of which the other options should be compared.

Mitral valve repair in children has the advantage of avoiding mitral valve replacement with its attendant need for anticoagulation and reoperation. Seventy-nine children between the ages of 2 months and 17 years (mean 4.9 years) underwent mitral valve repair between May 1982 and April 1993. There were five patients with mitral stenosis and 74 patients with mitral regurgitation, and 19 children were less than 2 years of age. Patients were divided into anatomic subgroups on the basis of the primary cardiac pathologic condition. Forty-three had severe mitral regurgitation, 21 had moderate mitral regurgitation, and 12 patients with primum atrial-septal defect and 2 patients with univentricular hearts had minimal to moderate mitral regurgitation. Associated cardiac anomalies were present in 68 patients and 85 % of the patients required concomitant intracardiac procedures. The methods of mitral valve repair included Annuloplasty in 68 (86%), repair of cleft leaflet in 41(52%), chordal shortening in 9 (11%), triangular leaflet resection in 8 (10%), splitting of papillary muscles with resection of subvalvular apparatus in 7 (9 %), and chordal substitution in 1(1 %). The technique of annuloplasty was modified to allow for annular growth. Follow-up was available from 1 to 10 years (mean 4 ± 2.5 `years). There were three early deaths (4%), all occurring as a result of low output cardiac failure in patients with minimal postoperative mitral regurgitation. Three late deaths (4%) occurred in patients with persistent moderate to severe mitral regurgitation and progressive cardiac failure and eight patients (10%) required either rerepair or replacement of the mitral valve. Actuarial survival was 94% at 1 year, 84 % at 2 years, and 82 % at 5 years, and actuarial freedom from reoperation was 89 % at 8 years. All patients received postoperative echocardiography with 82% having minimal to no mitral regurgitation and 98% of long-term surviving patients being free of symptoms. We conclude that mitral valve repair can be done with low early and late mortality. The need for reoperation is relatively low and valve growth has occurred with the use of a modified annuloplasty.

Background The left ventricular assist device (LVAD) is used as a bridge to heart transplantation. Currently, these devices are being used for longer periods of time than in previous years for the purpose of bridge to life, thus the need for dental assistance will emerge. Case description A female with severe acute congestive heart failure, owing to dilated cardiomyopathy, needed implantation of an LVAD as a bridge to heart transplantation. Six months after insertion of the device she suffered from spontaneous gingival bleeding and sought dental treatment. She presented with several dento-medical problems that required resolution before commencement of dental treatment. Conclusions Management of a patient with LVAD opens new frontiers for the dental team regarding treatment of the medically severely compromised patient who may present with multiple intervening medical aspects: profound antithrombotic therapy, high risk of device infection, possible magnetic interference with dental instruments, and even assessment of vital signs.

Background: Mitral valve replacement in patients who previously had undergone aortic valve replacement is a technical challenge. The rigid aortic prosthesis limits visualization of the anterior mitral annulus and placement of sutures. Methods: Reoperative mitral valve replacement was performed in five patients after aortic valve replacement. Two patients underwent resternotomy to allow verification of normal aortic prosthetic valve function. Anterolateral right thoracotomy was used for reentry in the remaining three patients. Exposure of the anterior mitral annulus was accomplished by initial traction on the intact anterior leaflet, with resection of this leaflet only after placement of sutures. Results: All patients survived the surgical procedure and are well 2 to 30 months after operation. In one patient it was impossible to open one cusp of the mitral prosthesis, nor was it possible to rotate the valve. The valve was reimplanted, but sutures were tied only after testing for full free cusp motion. Conclusions: When appropriate, right thoracotomy incision offers excellent exposure of the mitral valve with minimal dissection. Placement of sutures along the anterior portion of the annulus is facilitated by traction downwards on the anterior leaflet. Full range of motion of the prosthetic cusps should be verified before tying the sutures.

Thoracoabdominal aortic aneurysm repair requires complex surgery. Clamping of the descending aorta during the operation results in organ malperfusion, ischemia, and in some cases, irreversible end-organ damage and death. Several methods for organ preservation during the operation evolved, resulting in decreased post-operative organ malfunction. Re-attachment of intercostal arteries, cerebrospinal fluid drainage, and temporary bypass of the clamped aorta and selective perfusion of the spinal cord, intestine, liver and kidneys are widely used during the operation.To determine the impact of implementation of protective measures on the outcome of thoracoabdominal surgery over a decade.Between March 1993 and March 2003, 11 patients (age 41-80 years, average 60 years) underwent thoracoabdominal aortic aneurysm repair in our hospital. Different methods for organ preservation were used during the operation.The early survival is 91%. One patient suffered from paraplegia and one from mild temporary paraparesis. Two patients died during the follow-up period (at 5 months from pneumonia and at 2 years from aortic arch rupture).Implementation of all adjuncts to protect the organs dependent on aortic perfusion may eliminate the ischemic consequences of aortic clamping.

About 40% of patients with infective endocarditis will require surgical treatment. The guidelines for such treatment were formulated by the American College of Cardiology and American Heart Association in 1998.To examine our experience with surgical treatment of infective endocarditis in light of these guidelines.Surgery was performed in 59 patients with infective endocarditis between 1990 and 1999. The patients' mean age was 48 years (range 13-80). The indications for surgery were hemodynamic instability, uncontrolled infection, and peripheral embolic events. The surgical treatment was based on elimination of infection foci and correction of the hemodynamic derangement. These objectives were met with valve replacement in the majority of patients. Whenever conservative surgery was possible, resection of vegetation and subsequent valve repair were performed and the native valve was preserved.Six patients (10%) died perioperatively from overwhelming sepsis (n = 3), low cardiac output (n = 2) and multiogran failure (n = 1). The mean hospital stay was 15.6 days. Of 59 patients, 47 (80%) underwent valve replacement and in 11 (19%) the surgical treatment was based on valve repair. After 1 year of follow-up there was no re-infection.The new guidelines for surgical treatment of infective endocarditis allow better selection of patients and timing of surgery for this aggressive disease, which consequently decreases the mortality rate. Valve repair is feasible and is preferred whenever possible. According to the new guidelines, patients with neurologic deficit in our series would not have been operated upon, potentially decreasing the operative mortality to 7%.

Background— Ischemia on thallium scanning is a strong predictor of long-term mortality in CAD patients. Whether coronary revascularization (CR) in patients with significant ischemia on preoperative thallium scanning (PTS) improves long-term survival after major vascular surgery has not been determined. Methods and Results— The perioperative data, including PTS and subsequent CR in patients with moderate to severe reversible ischemia on PTS, and long-term survival of 502 consecutive patients who underwent 578 major vascular procedures were analyzed retrospectively. Patients with PTS who ultimately did not undergo the planned vascular operation were also studied. Cox regression and propensity score analyses were used to analyze survival. A total of 407 patients (81.1%) had PTS: 221 (54.3%) had no or mild defects (group I); 50 (12.3%) had moderate-severe fixed defects (group II); 62 (15.2%) had moderate-severe reversible ischemia yet did not undergo CR (group III); and 74 (18.2%) had moderate-severe reversible ischemia and subsequent CR by CABG (36) or PTCA (38; group IV). Patients who sustained major complications as a result of the preoperative cardiac workup were included in group IV. By multivariate analysis, age, type of vascular surgery, presence of diabetes, previous myocardial infarction, and moderate-severe ischemia on PTS independently predicted mortality ( P =0.001, 0.009, 0.039, 0.006, and 0.029, respectively), and preoperative CR predicted improved survival (OR 0.52, P =0.018). Group IV had better survival than group III even when subdivided according to normal and reduced left ventricular function (OR 0.40 and 0.41, P =0.035 and 0.021, respectively). Conclusions— Long-term survival after major vascular surgery is significantly improved if patients with moderate-severe ischemia on PTS undergo selective CR.

Fractures of the sternum may be associated with major injuries to thoracic organs, with serious consequences.To assess the hospital course of patients diagnosed with isolated sternal fracture.We reviewed 55 medical records of patients who were admitted with isolated sternal fracture to the emergency department during the period January 1990 through August 1999.Fifty-one patients were involved in motor vehicle accidents, and 4 sustained the injury as the result of a fall. Lateral chest X-ray upon admission was diagnostic in the majority of these patients (n = 53). Electrocardiography (n = 52) was abnormal in four patients--old myocardial infarction (n = 1), non-specific ST-T changes (n = 3). Cardiac enzymes (creatine-kinase-MB, n = 42) were pathologically elevated in five patients. Echocardiography, performed in patients with ECG abnormalities and/or elevated myocardial enzymes (n = 7), was normal in these patients as well as in another 18 patients. There were no intensive care unit admissions or arrhythmias during the hospital stay, which ranged from 6 hours to 6 days (mean 2.3 +/- 1.3 days, median 2 days).Our findings support the view that patients with isolated sternal fracture and no abnormality in ECG and cardiac enzymes during the early hours after injury are expected to have a benign course and can be discharged home from the emergency room within the first 24 hours.

A44-year-old woman was admitted to our institution with a history of shortness of breath on mild exertion, cough, fever, and weight loss of 20 pounds. Past history was not significant until 2 months before the hospitalization, when she developed weakness and cough with occasional mucoid sputum. She did not smoke or take any medication. Examination revealed no lymphadenopathy, jaundice, or neck vein engorgement …

The deleterious effect of hyperkalemic cardioplegic solutions on coronary endothelium has been documented and has also been demonstrated with University of Wisconsin solution. We evaluated a new extracellular University of Wisconsin formulation for efficacy in heart preservation. Six neonatal piglet hearts were arrested with and stored in the standard intracellular University of Wisconsin solution (group 1: K + 125 mEq/L, Na + 29 mEq/L). Six piglet hearts were preserved for 24 hours with an extracellular University of Wisconsin solution that differed only in the concentrations of potassium and sodium (group 2: K + 25 mEq/L, Na + 129 mEq/L). Hearts underwent modified reperfusion with leukocyte-depleted aspartate-glutamate enriched blood cardioplegic solution followed by conversion to a left-sided working mode on a Langendorff circuit with perfusion from a support pig. Stroke work index was calculated at left ventricular end-diastolic pressures of 3, 6, 9, and 12 mm Hg. Sixty minutes after reperfusion, there was no significant difference in stroke work index between group 1 (16.4 ± 1.9 × 1000 erg/gm) and group 2 (15.3 ± 2.7 × 1000 erg/gm). There was also no significant difference in high-energy phosphate stores or myocardial water content between the two groups. Extracellular University of Wisconsin solution provides myocardial preservation equivalent to standard University of Wisconsin solution while preventing exposure of coronary endothelium to high levels of potassium, which justifies its use in clinical heart transplantation. (J THORAC CARDIOVASC SURG 1995;110:738-45)

The present study was undertaken to determine the value of abnormal late ventricular potentials on signal-averaged electrocardiograms (ECG) in identifying patients at risk of developing ventricular tachycardia or ventricular fibrillation in the early postoperative period after coronary artery bypass grafting. Signal-averaged ECGs were recorded immediately after operation in 72 patients. Abnormal late potentials were defined as the presence of 2 or 3 of the following: (1) root-mean-square amplitude of the last 40 ms of the QRS20 microV; (2) duration of the terminal QRS potentials (after 40 microV)or = 39 ms; and (3) high-frequency QRS duration120 ms (in patients with conduction defects, only the first 2 criteria were used). Abnormal late ventricular potentials were present on the immediate postoperative signal-averaged ECG in 26 of the 72 patients (36%). Life-threatening ventricular tachyarrhythmias occurred in 6 patients. Late potentials were present in all 6 patients, but only in 20 of 66 (30%) who did not develop ventricular tachyarrhythmias (p0.005) (sensitivity 100%, specificity 70%, predictive accuracy 72%). Of 12 pre- and perioperative variables examined by univariate and multivariate regression analysis, the presence of late potentials on the signal-averaged ECG and low cardiac output postoperatively were found to be independent predictors of life-threatening tachyarrhythmias.

Warm retrograde blood cardioplegia is frequently used for myocardial protection, despite experimental studies questioning the adequacy of capillary flow to the right ventricle and septum. The capillary distribution of retrograde blood cardioplegia in the human heart is unknown. Hearts from eight transplant recipients with the diagnosis of idiopathic or dilated cardiomyopathy were arrested in situ with cold blood cardioplegia and excised with the coronary sinus intact. Within 20 minutes of explantation, colored microspheres mixed in 37° C blood cardioplegia were administered through the coronary sinus at a pressure of 30 to 40 mm Hg for 2 minutes. Twelve transmural myocardial samples were taken horizontally at the level of midventricle and apex to determine regional capillary flow rates. When retrograde warm blood cardioplegia was administered at a rate of 0.42 ± 0.06 ml/gm/min, the left ventricle, the septum, the posterior wall of the right ventricle, and the apex consistently received capillary flow rates in excess of their metabolic requirements. The capillary perfusion of anterior and lateral walls of the right ventricle was marginally adequate to sustain aerobic metabolism. In explanted human hearts, retrograde blood cardioplegia provides adequate capillary flow to the left ventricle, the septum, the posterior wall of the right ventricle, and the apex; however, capillary flow to the anterior and lateral walls of the right ventricle is marginal. This study delineates the tenuous balance between supply and demand for right ventricular protection with warm continuous retrograde blood cardioplegia. (J THORAC CARDIOVASC SURG 1995;109:935-40)

Background New-onset atrial fibrillation after coronary artery bypass grafting is common. Medical therapy includes various antiarrhythmic drugs to control heart rate and restore sinus rhythm. The purpose of this study was to determine the duration of antiarrhythmic therapy after discharge from the hospital. Methods One hundred twenty-nine patients in whom new atrial fibrillation after coronary artery bypass grafting developed and successfully reverted to sinus rhythm were prospectively randomized at dismissal to receive antiarrhythmic therapy for 1 week (group A; n=44), 3 weeks (group B; n=42), or 6 weeks (group C; n=43). Patients were followed up for an additional 4 weeks after discontinuation of antiarrhythmic therapy for detection of recurrent atrial fibrillation. Results The incidence of new atrial fibrillation during the study period was 21.2% (256/1206). Among the 129 patients who consented to the study, conversion to sinus rhythm was accomplished with the following medications: amiodarone (group A, 82%; group B, 93%; group C, 88%; P = .29), digoxin (group A, 16%; group B, 7%; group C, 7%; P = .29), β-blockers (group A, 27%; group B, 19%; group C, 14%; P = .30), calcium channel blockers (group A, 2%; group B, 2%; group C, 0%; P = .60), quinidine (group A, 2%; group B, 2%; group C, 7%; P = .44), and procainamide (group A, 4.5%; group B, 2%; group C, 0%; P = .37). Follow-up was completed in 128 patients (99.2%). There was no significant difference in the recurrence of atrial fibrillation among groups (0%, 2%, and 0% for groups A, B, and C, respectively). Conclusions Patients with new atrial fibrillation after coronary artery bypass grafting, converted to normal sinus rhythm before hospital discharge, have a benign course. Antiarrhythmic therapy as short as 1 week may be appropriate in these patients.