Open Intracardiac Operations Research Articles

Con: Low-flow cardiopulmonary bypass is not the preferred technique for patients undergoing cardiac surgical procedures

ALTHOUGH LOW-FLOW cardiopulmonary bypass (CPB) is sometimes necessary in adults, periods of reduced flow are undesirable and should not be the preferred technique for CPB. The appropriate flow for CPB has been a subject of debate since the earliest cardiac procedures were performed. In 1957, Kirklin et al1 at the Mayo Clinic stated: “No detail of the theory and practice of the extracorporeal circulation of blood for open intracardiac operations has excited more partisan discussion than flow rates.” In that report, the authors concluded that “. . .perfusion flows of approximately 2.2 to 2.5 liters per minute per meter of body surface are necessary.”

Chalk in the prime.

After observations of cloudiness in the perfusion circuit at open intracardiac operations, laboratory experiments showed a precipitate in a Hartmann's solution (compound sodium lactate solution, Ringer-lactate) and sodium bicarbonate based priming fluid used for cardiopulmonary bypass. The precipitate was found to consist of calcium carbonate crystals. The crystals were not dissolved by adding plasma proteins, nor were they sufficiently cleared from the extracorporeal circuit by a 40 microns filter in the arterial line. The crystals may embolise in microvascular beds and thus be a cause of postoperative morbidity. The practice of adding sodium bicarbonate to the pump prime may be unnecessary.

A decade of experience with a left heart assist device in patients undergoing open intracardiac operation

AbstractOver a decade has elapsed since the first clinical application of our left heart assist device (LHAD). The basic concepts underlying its development evolved from prior experience in which, given adequate support time, less than total left heart bypass (LHB) was found to result in gradual improvement of depressed left ventricular function. Hence, the long‐held view that functional recovery of the heart could occuronlyunder conditions of total LHB seemed unsupportable by clinical realities. As a result, a simple LHAD was devised. Requiring only special silicone elastomer cannulas, the system uses a roller (or other continuous flow) pump and diverts blood from the left atrium to the ascending aorta. We believe a major asset of the system is the ability to separate the patient subsequently from the LHAD without need to re‐enter the thorax. This is accomplished by permanently occluding each cannula lumen with an obturator, thereby allowing the biocompatible cannulas to remain permanentlyin situ.To date, 27 patients have undergone LHAD support. Of 18 patients who could be separated from the device, half (9) were discharged from the hospital. Seven remain alive and well, the longest now more than 10 years after the operation. Although rarely needed, broadening operative indications in patients with severely compromised left ventricular function suggests that there will be continued need for a method of LHB for the foreseeable future.

Intracardiac surgery in infants under age 3 months: Predictors of postoperative in-hospital cardiac death

Data are reported on 142 infants less than 3 months old who left the operating room alive after an open intracardiac operation during the 13 years from January 1967 to July 1980. The probability of postoperative in-hospital cardiac death for acute postoperative heart failure (the most common mode of death in these infants) was found by multivariate logistic analysis to be significantly related only to the strength of pedal pulses, the pedal skin temperature and the cardiac index in the first 5 postoperative hours. When cardiac index was not analyzed and cold cardioplegic myocardial preservation methods used, only pedal pulses and pedal skin temperature were significant predictors of hospital death. Blood pressure and heart rate were not related to this mode of hospital death. Oliguria occurred in 23 percent of patients; it was related primarily to inadequate cardiac performance and increased the probability of hospital death. Treatment protocols are derived based on these facts.

Intracardiac surgery in infants under age 3 months: Incremental risk factors for hospital mortality

During the 13 year period from January 1967 to July 1980, the hospital mortality rate for open intracardiac operations in infants in the first 3 months of life was 43 percent (75 deaths among 194 patients), higher than the 22 percent mortality rate (35 deaths in 161 patients) for closed operations in the same age group. The mortality rate was lower late in the experience (p = 0.0001). Poor preoperative condition of the patient increased the mortality rate 87 percent in patients preoperatively acidotic or in shock [preoperative class V]and 22 percent in patients with moderate or severe symptoms but without recent hemodynamic deterioration (preoperative class II or III). The presence of major associated cardiac lesions increased hospital mortality (p < 0.0001). The hospital mortality rate was highest (59 per cent) in infants less than age 1 month, possibly in part because of their sensitivity to the damaging effects of cardiopulmonary bypass. This hypothesis is supported by the association of a long period of cardiopulmonary bypass with increased hospital mortality (p = 0.05) and of total circulatory arrest during profound hypothermia with decreased mortality (p = 0.05). Most deaths (72 percent) occurred in association with acute postoperative cardiac failure. The length of cardiac ischemia (aortic cross-clamping time) was directly related to the probability of cardiac death, unless cold cardioplegia was used. Thirteen percent of the hospital deaths were associated with acute postoperative respiratory failure. Current mortality rates in typical cases without acute hemodynamic deterioration is estimated from these data to be 7 percent (70 percent confidence limits 4 to 12 percent), as a result of the scientific advances made over this period of time. Research into mechanisms of the damaging effects of cardiopulmonary bypass should further improve results in these very young patients.

Dynamic analysis of the blood pressure response to hypotensive agents, studied in postoperative cardiac surgical patients

The response of mean arterial blood pressure to infusion of hypotensive agents was studied in seven patients early after open intracardiac operation using a pseudorandom testing technique. Analysis of the impulse responses obtained confirmed that the method characterized the dynamic aspects of the pressure responses to these agents. This technique offers considerable promise for system identification in the adaptive control of therapeutic interventions in the intensive care unit.

The Application of a Semiautomated Postoperative Care Program in a Community Hospital: Early Results

The clinical involvement of computer technology in a medical center environment has been successfully utilized in the postoperative care of patients following open intracardiac operations. This report describes the initial experience in a community hospital with the adaptation and evaluation of such a system in the postoperative care of critically ill patients. The early experience with this noncomputerized system suggests the clinical usefulness of the approach, the potential increase in manpower utilization, and the greater utilization of the nursing staff in true patient care. The early results of the study do not indicate that this approach to patient care is necessarily economically feasible or technically applicable in all community hospitals.

Left Atrial Vent Device

A right angle sump catheter device for use in venting the left side of the heart through the left atrium during operations using cardiopulmonary bypass has been described. Design features were based upon aspiration of the most dependent portion of the left atrium. It has proven useful in rendering a dry operating field. Aspiration of blood returning to the left side of the heart during cardiopulmonary bypass from bronchial or aorto-pulmonary collateral circulation is necessary in many open intracardiac operations. Traditionally, this blood has been removed through a catheter inserted through the apex of the left ventricle. This method has generally been satisfactory, but problems associated with catheter position in trabeculae of the left ventricle, control of suction, damage to the ventricular myocardium, and risk of hemorrhage have led to use of the left atrium as the venting site of choice in most instances. A vent catheter inserted into the left atrium offers major safety and convenience factors, as well as placing the aspiration catheter at the most dependent point in the heart. A right angle sump device has been designed and used in over 500 open intracardiac procedures. It has proven to be very effective and essentially problem free in removing blood from the left atrium.

Cardiac output determination in infants and small children after open intracardiac operation : O. Alfieri and S. Subramanian. Ann. Thorac. Surg. 19:322–326 (March), 1975

Cardiac output determination in infants and small children after open intracardiac operation : O. Alfieri and S. Subramanian. Ann. Thorac. Surg. 19:322–326 (March), 1975

Fibrinolysis in cyanotic and acyanotic children before and after open intracardiac operations with the Bentley Temptrol oxygenator

Fibrinolysis in cyanotic and acyanotic children has been studied before and after open intracardiac operations. Preoperatively, shorter lysis times were found in the cyanotic group. Lysis times in individual patients varied at different times before operation. Precise documentation of the timing of fibrinolysis determinations is necessary. The lysis times appear to be affected by variables such as fasting, stress, and anesthesia in addition to perfusion. Postoperatively there was no excessive fibrinolysis in either the cyanotic or acyanotic group, the groups showing no differences. No significant alterations in plasma fibrinogen were present before or after perfusion with the pediatric Bentley Temptrol system.

Cardiac Output Determination in Infants and Small Children After Open Intracardiac Operations

Simple postoperative clinical observations of infants and small children are not truly objective or reliable. Direct measurement of cardiac output by means of a thermodilution catheter inserted at the time of operation has been used in conjunction with a computer in infants and small children. The technique is simple and can be done rapidly and repeatedly. The effects of various modes of cardiac stimulation can be assessed and the optimal method of treatment employed.

Implanted heart assist device after intracardiac surgery.

IN recent years there has been a steady decline in mortality after open intracardiac operations. However, persistent low cardiac output remains one of the prime causes of death, particularly in patients with far advanced myocardial dysfunction at the time of operation. These patients may manifest low output when attempts are made to discontinue cardiopulmonary bypass or 24 to 48 hours later, when cardiac performance is often at its lowest level. In such situations mechanical circulatory assistance may provide the only means of survival. Intra-aortic balloon counterpulsation has been effective in improving the hemodynamic state of patients in low output after . . .

Osmolal balance after open intracardiac operations in children: P.B. Deverall, D.C. Murs, F.J. Macartney, and J.D. Settle. Thorax 28, 756–761 (November), 1973

Osmolal balance after open intracardiac operations in children: P.B. Deverall, D.C. Murs, F.J. Macartney, and J.D. Settle. Thorax 28, 756–761 (November), 1973

Osmolal balance after open intracardiac operations in children.

Deverall, P. B., Muss, D. C., Macartney, F. J., and Settle, J. D. (1973). Thorax, 28, 756-761. Osmolal balance after open intracardiac operations in children. Changes in plasma osmolality, urine osmolality, urine volume, total osmolal output, and free osmolal output have been studied in children between 2 and 10 years of age. All underwent elective open intracardiac operations. Plasma hypo-osmolality develops after operation, and this was not influenced by altering the osmolal concentration of the prime in the extracorporeal system nor was it affected by severe water restriction in the immediate postoperative period. During the first 48 hours a water diuresis was not seen even in the presence of marked plasma hypo-osmolality. Urine volume, urine osmolality, and solute concentration in the kidney are affected by both the perfusate prime and postoperative fluid regime. As the total osmolal output was the same in all study groups, there was an inverse relation between urine volume and urine osmolality. The data obtained show no evidence of postoperative renal dysfunction. Free osmolal output, a measure of solute and water excretion, showed a normal renal response to a solute load but an abnormal response to a water load. The data support the use of moderate haemodilution in the perfusate prime, the precise osmolal concentration not being of major importance. Postoperatively a regime of moderate fluid restriction is supported.

Spontaneous breathing with continuous positive airway pressure after open intracardiac operations in infants : S. Stewart III, L. H. Edmunds, Jr., J. W. Kirklin, and R. R. Allarde. J Thorac Cardiovasc Surg 65:37–44 (January), 1973

Spontaneous breathing with continuous positive airway pressure after open intracardiac operations in infants : S. Stewart III, L. H. Edmunds, Jr., J. W. Kirklin, and R. R. Allarde. J Thorac Cardiovasc Surg 65:37–44 (January), 1973

Spontaneous breathing with continuous positive airway pressure after open intracardiac operations in infants

Spontaneous breathing with continuous positive airway pressure after open intracardiac operations in infants

Effect of alterations in arterial pressure on cardiac performance early after open intracardiac operations

Effect of alterations in arterial pressure on cardiac performance early after open intracardiac operations

Potassium intake and balance after open intracardiac operations

Potassium intake and balance after open intracardiac operations

Changes in colloid osmotic pressure during and shortly after open intracardiac operation

Changes in colloid osmotic pressure during and shortly after open intracardiac operation

The Tetralogy of Fallot, From a Surgical Viewpoint.

The surgical treatment of tetralogy of Fallot is and has been a great challenge to the cardiovascular surgeon. The ability to transform a severely cyanotic child with limited physical capacity and life expectancy to a healthy thriving acyanotic state is a miraculous deed. This feat has been possible only in the last two decades. The skills required to accomplish this task have touched many areas of medicine and science. John Kirklin, MD, one of the most knowledgeable and skillful cardiovascular surgeons, and his associate have adeptly written a monograph describing in precise terms the many facets of the management of tetralogy of Fallot. This book includes chapters dealing with definition, morphology, hemodynamics, life history, clinical features and diagnosis, open intracardiac operation, treatment during the postoperative period, results of intracardiac repair, palliative operations, indications for operation, and the treatment of congenital pulmonary atresia with ventricular septal defect. There are many