Use of a venous assist device after repair of complex lesions of the right heart

Sixteen patients underwent hemodynamic evaluation of a venous assist device after complex operations on the right side of the heart. The device consists of an inflatable abdominal binder attached to a Jobst extremity pump causing intermittent external compression of the abdomen. In addition, six of these patients were evaluated using total lower body compression for comparison. Modifications of the Fontan procedure were performed in 14 patients, mitral valve anuloplasty and tricuspid valve replacement in 1 patient and reconstruction of the right ventricular outflow tract for treatment of pulmonary atresia with intact septum in 1 patient. The patients' ages ranged from 23 months to 31 years (mean 10.7 ± 1.8 years). Systemic blood pressure, right and left atrial pressures, heart rate and arterial-mixed venous oxygen saturation difference were recorded in each patient with and without the device in place.With the venous assist device, mean systolic pressure increased from 95 ± 4 to 122 ± 3 mm Hg (p < 0.05) and diastolic pressure rose from 57 ± 3 to 70 ± 3 mm Hg (p < 0.05). Left atrial pressure increased from 7 ± 1 to 15 ± 1 mm Hg and right atrial pressure from 15 ± 1 to 23 ± 1 mm Hg (both p < 0.05). In addition, arterial-mixed venous oxygen saturation difference decreased from 29% without the device to 23% with the device in place (p < 0.05). Total lower body compression gave similar results to intermittent abdominal compression alone.Use of the venous assist device improves postoperative circulatory performance in patients after complex procedures on the right side of the heart. Cardiac filling pressures and systemic blood pressure rose while peripheral perfusion was improved. The ease and effectiveness of application of abdominal compression alone offer some advantage over the previously described technique of total lower body compression

Coronary sinus ostial occlusion during retrograde delivery of cardioplegic solution significantly improves cardioplegic distribution and efficacy

AbstractThis 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

Decreasing survival benefit from cardiac transplantation for outpatients as the waiting list lengthens

AbstractMany patients are accepted for cardiac transplantation during a period of clinical instability associated with a high risk of death, even though most can be discharged home to await transplantation. As the waiting lists lengthen, priority is awarded solely on the basis of the waiting time of outpatients, who now usually undergo transplantation after they have already survived a major period of jeopardy. To determine the impact of the current waiting times and priority system on the previously expected benefit offered by transplantation, 1-year actuarial survival without transplantation was recalculated after each month without transplantation for 214 potential candidates with an ejection fraction of 0.17 ± 0.05 discharged on tailored medical therapy after evaluation. These data were compared with the 1-year survival data of 88 outpatients who underwent transplantation.Actuarial survival after 1 year was 67% on tailored therapy compared with 88% after transplantation (p = 0.009). Death without transplantation was sudden in 43 of 51 patients, resulting from hemodynamic decompensation in 8. For outpatients already surviving 6 months without transplantation, actuarial survival over the next 12 months was 83% without transplantation. Thus, the expected improvement in survival after transplantation would be only 5% over the subsequent year for patients waiting 6 months, which is the waiting time for many outpatients. Such patients should be reevaluated to determine whether transplantation remains indicated during the next year