Search

There are more than 120 cardiac surgery programs in California. More than half perform less than 200 coronary artery bypass graft (CABG) procedures per year. This study queried the state of California discharge abstract database to analyze the relationship between annual procedural volume and outcomes of all 119 nonfederal hospitals performing cardiac surgery during 1997 through 1999. Unadjusted in-hospital mortality for CABG surgery was 3.91 per cent (923 of 23,619) in hospitals performing fewer than 200 procedures per year and 2.09 per cent (496 of 23,704) in hospitals performing ≥500 procedures annually ( P = 0.001 by Chi-square). Similar findings were noted for CABG + valve and/or aneurysm and for valve procedures. Risk-adjusted CABG data obtained from 78 of 119 hospitals found that a significant difference persisted between a volume of

We evaluated the hemodynamic effects of amiodarone on left ventricular (LV) function after global ischemia. Amiodarone was administered orally at 15 mg/kg/day for an average of 28 days to a group of 10 dogs. The concentration of amiodarone in serum and LV myocardium was 0.40 +/- 0.24 micrograms/ml and 44 +/- 27.0 micrograms/g, respectively. This experimental group and a control group of 10 dogs each underwent 120 min of aortic cross-clamping with cold crystalloid cardioplegia resulting in an average myocardial temperature of 15 degrees C. LV function measurements by pulse-transit sonomicrometry and Millar solid-state micromanometers were processed by a minicomputer. Compared to the nontreated control group, oral amiodarone for 28 days produced depression of LV contractility which was reflected by lower slope of the end-systolic pressure-volume relation (Evmax), percentage shortening of segment length, left ventricular pressure-segment length loop area, and slope of the end-systolic pressure-segment length relation (Esmax). After ischemia, percentage recovery of LV global function (Evmax and mean velocity of circumferential fiber shortening) and regional function (Esmax) was significantly better in the amiodarone group than in the control group. We conclude that oral amiodarone for 28 days results in a depression of LV contractility but the combination of amiodarone and ischemia does not act synergistically to further depress postischemic LV function.

Over the 3-year period from Jan. 1, 1986, through Dec. 31, 1988, we have implanted 101 automatic implantable cardioverter-defibrillators into patients with life-threatening ventricular arrhythmias. There were 82 male patients and 19 female patients. The mean age was 58 years with a range of 25 to 82 years. The indication for implantation was ventricular fibrillation in 89 patients and recurrent ventricular tachycardia in 12 patients. Seventy-seven patients had a history of prior myocardial infarction or coronary artery disease, or both. Eighteen patients had nonischemic cardiomyopathy. One patient had a prolonged QT syndrome and five patients had no evidence of preexisting structural heart disease. The mean injection fraction was 37% ± 17%. Forty-one of the automatic implantable cardioverter-defibrillator implantations were associated with procedures necessitating cardiopulmonary bypass. The hospital mortality rate was 4% and the morbidity rate was 15%. The only statistical difference between those patients who did and did not have postoperative complications was a history of a prior myocardial infarction (90% versus 54%, p

TABAYASHI, K., MCKEOWN, P.P., MIYAMOTO, M., LUEDTKE, A.E., THOMAS, R., BREAZEALE, D.G., MISBACH, G.A., ALLEN, M. and IVEY, T.D. Myocardial Preservation: A Comparison of Oxygenated Crystalloid and Blood Cardioplegia. Tohoku J. Exp. Med., 1990, 161 (3), 185-197-The purpose of this experiment was to compare myocardial protective effect after global ischemia using oxygenatedcrystalloid (CCcO2) and an oxygenated blood (BCcO2) cardioplegic solutions. Post-ischemic ventricular performance was studied in 2 equal (n=7) groups of dogs subjected to 120min of global ischemia induced at average myocardial temperatures of 8°C in the CCcO2 group and 18°C in the BCcO2 group. Left ventricular (LV) function included analysis of LV systolic function (global and regional function), LV diastolic function (chamber and myocardial stiffness) and LV relaxation was measured by sonomicrometry and Millar micrometers. Data were processed with a Dec PDP-11/23 computer. In vitro oxygen content (Vol%) measured 3.2±1.0 (CCcO2) and 9.5±0.3 (BCcO2). Percent recoveries of LV global function (LVSP, loop area, % shortening, LV dp/dt, mean VCF and E max) in the CCcO2 group were approximately the same as those in the BCcO2 group. There were no significant differences in LV regional function (loop area and % shortening) after ischemia between the two groups. The chamber and myocardial stiffness after ischemia in the CCcO2 group were almost the same as the baseline values. Values in the BCcO2 group were reduced significantly compared to the baseline level. There were significant differences in post-ischemic chamber and myocardial stiffness between the two groups. Post-ischemic maximum negative LV dp/dt in both groups decreased significantly compared to the baseline values. However, the time constant and diastolic interval after ischemia in both groups were approximately the same as the baseline values. We conclude that there were no significant differences in myocardial protective effect between the CCcO2 and BCcO2 groups, and both methods preserved the ischemic myocardium well.

Background In-hospital mortality is frequently used as an outcomes measure for surgical procedures. Recently, hospitals have developed subacute care facilities to allow earlier discharge. Outcomes of patients discharged (transferred) to these units or to other similar facilities may not be captured in reports of in-hospital mortality. Study design The California Office of Statewide Health Planning and Development (OSHPD) patient discharge abstract database was examined to determine the rates of discharge to other facilities (transfer) and the number of in-hospital deaths occurring during the index hospitalization and after transfer in patients undergoing cardiac surgery procedures. Data were collected for 1997, 1998, and 1999 for coronary artery bypass grafting (CABG-only, n=82,897), CABG plus additional procedures (CABG-plus, n=11,869), and valve repair or replacement (Valve-only, n=14,872). In-hospital mortality and transfer rates (same-day discharge and readmission to another facility) were determined for all hospitals through the index hospitalization and subsequent transfers. Results Aggregated 3-year in-hospital mortality rates for the index hospitalization were 2.98% for CABG-only, 9.25% for CABG-plus, and 4.85% in Valve-only groups. Transfer rates were 12.41%, 23.16%, and 13.43%, respectively. The percentages of all in-hospital deaths occurring after transfer from the index hospital were 13.5% (385 of 2,857) in CABG-only, 13.3% (168 of 1,266) in CABG-plus, and 11.0% (89 of 811) in Valve-only patients. When corrected for these additional deaths, the actual in-hospital mortality rate was 3.45% for CABG-only, 10.67% for CABG-plus, and 5.45% for Valve-only procedures. Conclusions Transfer to another healthcare facility rather than discharge home is a common practice after cardiac surgery. A substantial percentage of in-hospital deaths occurs after discharge from the primary institution.

There are more than 120 cardiac surgery programs in California. More than half perform less than 200 coronary artery bypass graft (CABG) procedures per year. This study queried the state of California discharge abstract database to analyze the relationship between annual procedural volume and outcomes of all 119 nonfederal hospitals performing cardiac surgery during 1997 through 1999. Unadjusted in-hospital mortality for CABG surgery was 3.91 per cent (923 of 23,619) in hospitals performing fewer than 200 procedures per year and 2.09 per cent (496 of 23,704) in hospitals performingor = 500 procedures annually (P = 0.001 by Chi-square). Similar findings were noted for CABG + valve and/or aneurysm and for valve procedures. Risk-adjusted CABG data obtained from 78 of 119 hospitals found that a significant difference persisted between a volume of200 andor = 200 procedures per year (P = 0.03 by t test). There was wider variation in outcome among lower-volume hospitals. However, many low-volume providers had excellent results. It is concluded that although volume is clearly related to outcome patient-related factors and process variables may be more important. Performance improvement programs should be developed to improve communication between providers with differing outcomes.

The optimal management of patients with small aortic anulus or left ventricular outflow tract obstruction remains unclear. Between 1976 and March, 1982, 18 patients have undergone enlargement of their left ventricular outflow tract by means of the Konno or a modification of the Konno procedure. Fourteen of these 18 patients had previous operations for aortic stenosis or tunnel left ventricular outflow tract, and two patients had undergone three previous operations. All 18 patients had symptoms of either heart failure or chest pain, or had electrocardiographic evidence of strain. They ranged in age from 4 years to 58 years, with 13 of the 18 patients being less than 20 years of age. A Dacron patch was used to enlarge the left ventricular outflow tract after incising down the ventricular septum. In all patients, at least a 21 mm valve could be placed, with between 50% and 65% of the valve anulus being made up of natural tissue. The remaining portion of the valve anulus was constructed from the Dacron patch. The patch was extended up to enlarge the ascending aorta, and a pericardial patch was used to close the defect in the right ventricular outflow tract. In all 18 patients the gradient was obliterated at the time of operation. There was one early death in a patient who had previous insertion of a left ventricular apical-aortic conduit in which the heterograft valve had degenerated. There has been one late death because of bacterial endocarditis in a child who also had a parachute mitral valve and evidence of pulmonary hypertension. The remaining 16 patients are functioning well after the Konno procedure. Three are receiving warfarin sodium, and 13 are receiving aspirin. These results suggest that this is an acceptable method of treating patients with small aortic anulus or left ventricular outflow tract obstructions and would appear to have advantages over a left ventricular apical-aortic conduit.

To determine if the prophylactic administration of oral verapamil is effective in reducing the incidence of supraventricular tachycardia after myocardial revascularization, 141 patients were entered into a double-blind randomized trial. Seventy patients received verapamil 80 mg every 8 hours beginning immediately after operation and continuing for 5 days, and 71 patients received placebo. Patients were monitored during the study period and observed for the occurrence of supraventricular tachycardia. The verapamil and placebo groups were similar with regard to sex, age, preoperative antianginal drugs, number of bypass grafts, average bypass time, and average occlusion time. A total of 39 patients had supraventricular tachycardia, 20 were receiving verapamil, and 19 were receiving placebo. The average ventricular rate was 127 +/- 13 beats/min for the verapamil group with supraventricular tachycardia compared with 140 +/- 12 beats/min for the placebo group with the mean differences not significant (p = 0.10). On the basis of these data, it is concluded that verapamil 80 mg every 8 hours beginning early after myocardial revascularization is not effective in reducing the incidence of supraventricular tachycardia.

In general, it has been thought that pulmonary valve insufficiency is well tolerated when the valve is excised or when the pulmonary annulus has been widened with an outflow patch during repair of tetralogy of Fallot. However, when pulmonary regurgitation is massive or when it is combined with other causes of right ventricular failure, progressive right ventricular dilation may occur in some patients. Pulmonary valve replacement has not been commonly used in the past. From January, 1980, to August, 1982, 12 patients, 11 months to 17 years old, had pulmonary regurgitation treated by insertion of a valve in the pulmonary position 4½ months to 11 years after initial repair of tetralogy of Fallot. All patients had progressive right ventricular failure not responsive to medical management. There were no major outflow tract obstructions, residual ventricular septal defects, or persistent aortopulmonary shunts. All 12 patients underwent patch reconstruction of the right ventricular outflow tract that allowed placement of a larger valve. There have been no operative or late deaths, and each patient has had improvement in functional status. One patient required tricuspid valve replacement 1½ years after pulmonary valve replacement to achieve sustained relief of symptoms. Only 1 other patient required subsequent operation; this was for pacemaker lead changes. These early results suggest that in patients with right ventricular failure, attention should be directed to pulmonary regurgitation since this is a component of failure that is reversible; pulmonary valve replacement carries a low risk, and it can relieve symptoms and prevent further deterioration of right ventricular function.

This study was designed to compare myocardial protection with a nonoxygenated crystalloid solution, an oxygenated crystalloid solution, and an oxygenated fluorocarbon cardioplegic solution. Postischemic ventricular performance was studied in three equal (N = 7) groups of dogs subjected to 120 minutes of global ischemia induced at an average myocardial temperature of 18.5° ± 1.4° C (range 17.0° to 21.0° C). Left ventricular global and regional function was evaluated by sonomicrometry and micromanometers before ischemia and at 45 and 60 minutes after ischemia. Stroke volume index, left ventricular pressure-minor external diameter loop area, percent shortening, first derivative of left ventricular pressure, mean velocity of circumferential fiber shortening, and the slope of the end-systolic pressure were used to evaluate myocardial contractility. In vitro oxygen content of the three cardioplegic solutions was measured at a mean injection temperature of 8.3° ± 0.6° C: 0.8 ± 0.1 vol% (nonoxygenated crystalloid cardioplegia), 3.2 ± 0.2 vol% (oxygenated crystalloid cardioplegia), and 6.2 ± 0.2 vol% (oxygenated fluorocarbon cardioplegia). Recovery of global and regional function was significantly (p

Most reports of operations for ventricular arrhythmia have dealt with patients with anterior myocardial infarction. Patients with previous remote inferior myocardial infarction and recurrent ventricular tachycardia or fibrillation are a difficult subset of patients to treat with surgical ablative procedures. Over a 2 year period, 11 patients with prior inferior myocardial infarction and drug-refractory ventricular tachycardia or fibrillation underwent elective operation to control the arrhythmia. Five patients had monomorphic ventricular tachycardia. Three of these five patients had localized endocardial resection and/or cryoablative procedures when the ventricular tachycardia was well localized intraoperatively. In the remaining two patients, ventricular tachycardia was noninducible intraoperatively, and the patients underwent extensive endocardial resection and mitral valve replacement because of sites suspected near the posterior papillary muscle from preoperative catheter mapping. None of these five patients had inducible ventricular tachycardia postoperatively, and all are clinically free of the arrhythmia over a 24 month follow-up period. One patient with two morphologies of ventricular tachycardia previously had an unsuccessful blind endocardial resection. She underwent map-directed cryoablation of both sites of ventricular tachycardia. Postoperatively, the patient was free of inducible arrhythmia and has been asymptomatic over 8 months. Five patients had pleomorphic ventricular tachycardia or fibrillation that could not be electrically localized. One patient with ventricular fibrillation underwent extensive endocardial resection, but the posterior papillary muscle was spared. Postoperative electrophysiological study was positive. The patient has had no clinical ventricular arrhythmias on a regimen of amiodarone, however. Two patients had extensive endocardial resection and mitral valve replacement. One died early in the postoperative course and the other is clinically well. The remaining two patients had an encircling endocardial ventriculotomy. Both are clinically stable although one had inducible ventricular fibrillation postoperatively. We conclude that well-defined monomorphic ventricular tachycardia in patients with a previous inferior myocardial infarction can be successfully treated with localized endocardial resection and/or cryoablation. However, patients with poorly localized monomorphic ventricular tachycardia or pleomorphic ventricular tachycardia or fibrillation may require more extensive procedures. The role of posterior papillary muscle sacrifice with mitral valve replacement remains undefined. The exact procedure cannot be anticipated and depends on both the type of clinical arrhythmia and the surgical anatomy.

It has been postulated that pulsatile blood flow helps to preserve the myocardium after ischemia. However, its effect on postischemic myocardium during cardiopulmonary bypass has not been clearly defined. To determine if pulsatile reperfusion improves postischemic recovery of cardiac metabolism and performance, we subjected 20 dogs to 60 minutes of aortic cross-clamping followed by 45 mminutes of pulsatile (P group; 10 dogs) or nonpulsatile (NP group; 10 dogs) reperfusion. Left ventricular function was measured at a controlled preload in both groups before induction of global ischemia and after termination of bypass. Segmental length (assessed by sonomicrometry) was used to determine dimensional changes. Ventricular pressures were measured with solid-state micromanometers. Percent recovery of left ventricular peak systolic pressure, its first derivative, and stroke work were 66%, 59%, and 38%, respectively in the NP group and 82%, 76%, and 65% in the P group. The postarrest decrease in segmental shortening was minimized in the P group; left ventricular function curves and the slope of the end-systolic pressure-length relationship also indicated better performance after pulsatile reperfusion than after nonpulsatile reperfusion. Myocardial lactate extraction was transiently improved during the early pulsatile reperfusion period. We conclude that pulsatile reperfusion provides better myocardial preservation than nonpulsatile perfusion after 60 minutes of induced global ischemia.

Summary This study has presented the spectrum of postoperative gastrointestinal system complications after open heart surgery at the University of Washington from 1980 through 1983. The frequent necessity for operative intervention and a mortality rate of 17 percent in our study of gastrointestinal complications in patients who have undergone open heart surgery indicates the need for early diagnosis and treatment. The data suggest that bypass times approaching 100 minutes and the presence of postoperative cardiogenic shock are important risk factors in the development of such complications in elective cardiac surgery patients. An incidence of gastrointestinal complications of 8.6 percent in those undergoing repair of acute aortic dissections makes gastrointestinal complaints particularly suspicious in this subgroup.

Closure of the ventriculotomy following ventricular aneurysm resection usually requires buttressing material to provide strength and hemostasis. Although Teflon felt has usually been used, this material is bulky, noncompliant, and prone to infection. Autologous pericardium appears to offer an ideal substitute without the disadvantages of artificial material. A simple technique is described to apply pericardial tissue as a natural buttressing agent for ventriculotomy closure.

To compare serial functional and perfusion scintigraphic changes after myocardial infarction, we performed left ventricular (LV) cineanglograms and thallium (Tl)-201 myocardial perfusion scintigrams before and 1 hour, 2 days, 9 days, and 1 month after closed chest coronary occlusion in 14 dogs as survival permitted. Survivors were studied with technetium-99m (stannous) pyrophosphate (TcPYP) scintigrams at 48 hours, and at postmortem examination infarction was documented and measured after nitroblue tetrazolium (NBT) staining. The TcPYP image was abnormal in 10 dogs, each of which had infarcts on NBT staining measuring 3 to 23 gm. In all 14 dogs, perfusion scintigrams became abnormal and LV ejection fraction (EF) fell when measured within 48 hours of occlusion. In the nine late survivors studied over 1 week after the event, perfusion scintigrams and EF improved in those which developed infarcts and normalized in those without infarction. The decrement in LVEF after coronary occlusion generally showed serial improvement and correlated with the size of the defect in the accompanying Tl-201 scintigram (r = 0.74). Tl-201 defect size seen in late studies correlated well with NBT infarct size (r = 0.89) and TcPYP image infarct size (r = 0.82), as it did with the decrement in LVEF noted in late studies (r = 0.86). The results suggest that early perfusion scintigrams together with TcPYP images may be useful for estimating the amount of reversible dysfunction after coronary occlusion.

Twenty-three patients with bacterial endocarditis and mycotic aneurysms of the aortic annulus were treated between 1978 and 1985. There were 18 men and 5 women ranging from 24 to 72 years old. All patients had congestive heart failure and positive blood cultures as a complication of the endocarditis and were in New York Heart Association (NYHA) Functional Class III or IV. The aneurysm complicated late prosthetic valve endocarditis in 7 patients and native valve endocarditis in 16. The most common infecting organisms were streptococci (12 patients) and staphylococci (7 patients). The noncoronary sinus was the most frequent site for aneurysm formation. Following debridement of the abscess cavity, the orifice of the aneurysm was closed with a patch of Dacron in 20 patients and autologous pericardium in 3. A prosthetic valve (18 bioprosthetic and 5 mechanical) was secured to the noninfected portion of the native annulus and to the patch at the level of annulus. There were 3 deaths, 1 perioperative and 2 late, each without evidence of residual infection or aortic insufficiency. There are 20 late survivors (87%). After a mean follow-up of 1 year, all patients are in NYHA Functional Class I. Patch closure of mycotic aneurysms involving the aortic annulus permits aggressive debridement of the abscess cavity and affords closure of the orifice without tension. The prosthetic valve can be seated at the level of the native annulus, thus avoiding complicated reconstructive procedures of the aortic root and coronary arteries. This technique is an effective alternative in selected cases of mycotic aneurysms involving the aortic annulus.

Several investigators have demonstrated acute, reversible shifts in the position of the diastolic, left ventricular pressure-volume curve (1,2,3 4,5,6). Upward shifts tend to be associated with conditions that increase the load against which the heart ejects or conditions which decrease the capacity of the heart to meet that load. Downward shifts have followed administration of the pharmacologic vasodilators nitroglycerin or nitroprusside and are presumably associated with a more advantageous relation of the contractile capacity of the heart to the load presented by the circulation.

During a 31 month period, 1,433 consecutive patients undergoing cardiac procedures were screened for carotid bruit. A total of 94 patients with carotid bruit were identified who had ultrasonic carotid duplex scans. Nine patients had a history of transient ischemic attack, carotid bruit, and reduction in internal carotid artery diameter by ≥50% according to ultrasonic carotid duplex scanning. All nine patients underwent carotid angiography followed by thromboendarterectomy prior to or simultaneous with cardiopulmonary bypass. There was one neurological complication leading to death in this subset. Sixteen patients with asymptomatic carotid bruit had ultrasonic carotid duplex scanning revealing an internal carotid artery lesion of ≥50% but did not undergo arteriography or thromboendarterectomy prior to the cardiac procedure. Perfusion pressure was maintained at ≥70 mm Hg during bypass. There were no focal neurological events in this subset. Sixty-six patients with internal carotid artery stenosis of