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Send to a FriendEarly repair of complete atrioventricular septal defect is safe and effective. Singh RR, Warren PS, Reece TB, Ellman P, Peeler BB, Kron IL. Ann Thorac Surg. 82:1598-601, 2006.
BACKGROUND: Surgical repair of complete atrioventricular septal defect (CAVSD) is a well-established procedure performed on young children. Our hypothesis is that with modern techniques, the current risks of CAVSD repair in children aged younger than 3 months and in children older than 3 months are equal. METHODS: This was a retrospective review of 65 infants and children with a mean age of 10.9 months (range, 1 month to 15.5 years) who underwent CAVSD repair from 1990 to 2004. Twenty-six repairs (40%) were done on or before 3 months of age (group A) and 39 repairs (60%) were done after 3 months of age (group B). In all patients, the ventricular septal defect was repaired with an individualized approach according to each patient's specific anatomy: direct suturing without a patch, interposition of a small pericardial patch with a running suture, or both. The atrioventricular commissure was closed with interrupted sutures, and all atrial defects were closed with a pericardial patch. Data were analyzed using the chi2 analysis and the Fisher exact test.
RESULTS: Three hospital deaths occurred (<30 days), 2 in group A and 1 in group B (7.7% vs 2.6%, respectively, p = 0.33). One death in group A occurred during another noncardiac surgery. Early reoperation (<1 year of initial surgery) for residual ventricular septal defect or significant mitral regurgitation, or both, occurred in 3 group A patients and in 4 group B patients (11.5% versus 10.3% respectively, p = 0.68). CONCLUSIONS: These results suggest that repair of CAVSD defects in children 3 months of age or younger had similar outcomes compared with those who underwent surgical repair after 3 months of age.
Coarctation of a right aortic arch. Maxey TS, Bradner MW, Reece TB, Keeling WB, Kron IL. J Card Surg. 21(3):261-3, 2006
Right-sided aortic arch with a concomitant coarctation is an exceedingly rare congenital cardiac anomaly. We report of a 4-year-old boy who presented with a history of a stenotic bicuspid aortic valve who upon further evaluation was found to have a coarctation of a right-sided aortic arch. The frequency with which other anomalies exist in either of the above conditions requires thorough cardiac evaluation and detailed imaging. Surgical repair of this anomaly can safely be undertaken through a right thoracotomy.
Elimination of fat microemboli during cardiopulmonary bypass. Kaza AK, Cope JT, Fiser SM, Long SM, Kern JA, Kron IL, Tribble CG. Ann Thorac Surg. 75:555-9, 2003.
BACKGROUND: Fat emboli have been implicated in cerebral dysfunction after cardiopulmonary bypass (CPB). We sought to identify the source of fat emboli during CPB and devise a technique for their elimination. METHODS: Patients undergoing CPB were prospectively randomized to either cardiotomy suction (n = 7) or cell-saving suction device (n = 6). Blood was collected at various intervals during CPB, and the fat emboli were identified using oil red O stain. These emboli were grouped based on their diameter into 10- to 50-microm and more than 50-microm particles. The number of fat emboli per slide examined was graded according to the following scale: 1 (1 to 10), 2 (11 to 20), 3 (21 to 30), and 4 (> 30 emboli). In the second phase of the experiment, a 21-microm filter was attached in series, distal to the cardiotomy reservoir (n = 6), and fat emboli were quantified. RESULTS: Blood from the pericardial well was saturated with fat emboli of both sizes. Patients randomized to the cardiotomy suction had a significantly higher number of fat emboli at the end of CPB when compared with those randomized to the cell-saving suction device and dual-filter group. Processed blood from both the cardiotomy reservoir and cell-saving device was noted to have an abundance of fat emboli when compared with blood processed through the dual filters.
CONCLUSIONS: Processed blood from both the cardiotomy reservoir and cell-saving device appear to have an abundance of fat emboli that are completely eliminated by using a 21-microm arterial filter in series with the cardiotomy reservoir. This intervention could potentially reduce neurocognitive dysfunction associated with CPB.
When to Discontinue Postcardiotomy Extra-corporeal Membrane Oxygenation. Fiser SM, Tribble CG, Kaza AK, Long SM, Zacour RK, Kern JA, and Kron IL. Ann Thorac Surg. 71(1):210-4, 2001.
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has demonstrated limited success in adult postcardiotomy shock. The goal of this study was to determine when to discontinue ECMO for postcardiotomy support. METHODS: During a 7-year period ECMO was used in 51 postcardiotomy patients, of whom 16 (31%) weaned and 8 (16%) survived. RESULTS: Patients in the heart transplant group were more likely to wean compared with patients in the non-heart transplant group (p = 0.03). Patients aged greater than 65 years (p = 0.04) or with ejection fractions of less than 30% after 48 hours of ECMO (p < 0.001) were less likely to wean. Time on ECMO was significantly longer for survivors in the heart transplant group (101.3 +/- 7.5 hours) compared with survivors in the non-heart transplant group (28.3 +/- 11.9 hours, p < 0.001). CONCLUSIONS: After 48 to 72 hours, consideration should be given to discontinuing ECMO, either by moving to an implantable ventricular assist device or by withdrawal of support, except in those patients with heart transplants. In the latter, both severe postoperative pulmonary hypertension and reperfusion injury may take as long as 120 hours to reverse.
Cardiac Reoperation in the Intensive Care Unit. Fiser SM, Tribble CG, Long SM, Kaza AK, Kern JA and Kron IL, Accepted for presentation at the Southern Thoracic Surgical Association Meeting, 2000, Marco Island, FL)
Introduction: At our institution, cardiac reoperations are routinely performed in the cardiac intensive care unit (ICU), as opposed to taking these patients back to the operating room. Our hypothesis was that reoperation in a cardiac ICU does not increase sternal infection rate.
Methods: A retrospective analysis was performed on 6908 adult patients undergoing cardiac surgery over a 9 year period. Excluding those in cardiac arrest, 340 (4.9%) patients underwent reoperation in the cardiac ICU, of which 289 survived (85%).
Results: Of the 289 patients that survived reoperation in the ICU, 6 developed wound infections that required operative debridement (2.1%, 6/289), which was not significantly different from those patients not requiring reoperation (1.9%, 121/6497, p = 0.70). Hospital charges for a 2 hour reoperation in the ICU and operating room are approximately $1,972/patient and $5,832/patient, respectively.
Conclusions: Reoperation in the intensive care unit does not increase in wound infection rate compared to those without reoperation. Decreased charges, avoiding transport of potentially unstable patients, quicker time to intervention, and convenience are advantages of reoperation in an ICU.
Cardiac Screening Prior to Non-cardiac Operations. Kron IL, Kern JA, Beller GA, Bergin J, Fiser SM, Gangemi JJ, McPherson JA, and Powers ER. Current Problems in Surgery. 37(6):426-33, 2000.
Foreword: Patients who undergo non-cardiac operation often have associated cardiovascular disease, which increases the morbidity and mortality rates of the operative procedure. This is becoming and especially important issue as the age of the population increases. Valuation of cardiac function in any patient who undergoes a surgical procedure is important; however, which studies should be performed and in what sequence remains controversial. Moreover, clinical screening must be viewed in the context of cost that is related to the benefit and the practicality of the study. In this issue of Current Problems in Surgery, Dr Irving L. Kron and his colleagues at the University of Virginia School of Medicine address this important topic. They first consider the issue of who should be screened and then review the various invasive and noninvasive procedures that have proved useful. A substantial part of this monograph is concerned with the specific interventional procedures that are indicated under various circumstances.
Does the additive risk mitral valve repair in patients with ischemic cardiomyopathy prohibit surgical intervention? Gangemi JJ Tribble CG, Ross SD, McPherson JA, Kern JA, and Kron IL. Annals of Surgery. 231(5):710-4, 2000.
Objective: To assess the surgical risk of additional mitral valve repairs in patients with ischemic cardiomyopathy.
Summary and Background Data: Severe mitral regurgitation in patients with ischemic cardiomyopathy increases the death rate and symptomatic status. The 1-year survival rate for medical therapy in this subset of patients is less than 20%. Transplantation is usually not feasible because of donor shortage and death while on the waiting list.
Methods: To assess additive risk, a retrospective chart review from 1993 to 1998 was performed comparing patients with ischemic cardiomyopathy (ejection fraction [EF] <25%) and severe mitral regurgitation undergoing mitral valve repair and coronary artery bypass graft operations with patients with an EF of <25% undergoing coronary artery bypass graft alone. These groups were also compared with 140 patients receiving heart transplants since 1993 (group 3). <br />Results: The overall hospital death rate for group 1 was 6.3%. The one death occurred 2 weeks after surgery secondary to sepsis. This was not significantly different from the death rate of 4.1% in group 2. In group 1, there were two deaths at 1 year (87% survival rate), one related to heart failure. One patient was New York Heart Association (NYHA) class IV at 1 year; the remainder of patients were NYHA class I-II. These results were not significantly different than the 8% death rate noted with transplantation. There was no change in EF and minimal residual mitral regurgitation in group 1 based on postoperative transesophageal echocardiography, whereas group 2 had an average 11.7% improvement in EF.
Conclusions: Previously, severe mitral regurgitation in the setting of ischemic cardiomyopathy has been associated with poor survival. In these authors' experience, repairing the mitral valve along with coronary artery bypass grafting does not increase the surgical risk, yields improvement in symptomatic status, and compares favorably to coronary artery bypass grafting alone and cardiac transplantation. However, the lack of change in EF in these patients probably represents an overestimation of the EF before surgery secondary to severe mitral regurgitation.