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Background Need for pacemaker or internal cardioverter defibrillator lead removal is increasing. Removal can be dangerous, difficult, or unsuccessful. Methods We retrospectively reviewed our results and the techniques we used in 365 patients from 1992 through 2009 for successful complete removal of leads and complications. Various techniques of extraction were analyzed for effectiveness and complications. The eras before (1992 to 1999) and after the availability of laser sheath extraction (2000 to 2009) are compared. Results Of 365 patients who underwent transvenous lead extraction, of which 235 were infected, and 130 had lead removal for noninfectious indication. Staphylococcus aureus was the infecting organism in 40%, and coagulase-negative Staphylococcus occurred in 33%. One-half of the organisms were methicillin resistant. Preimplant risk factors for infection included more than one device implant procedure in 105 (47%), preimplant Coumadin therapy (Bristol-Myers Squibb, Princeton, NJ) in 74 (31%), and hemodialysis in 9 (4%). Laser extraction became available in 2000. The era with the availability of laser extraction was associated with a better complete extraction rate (93% vs 89.55%) a lower bleeding rate (1.9% vs 3.1%), and complete extraction without the additional use of femoral workstation extraction tools. Mortality was 1.1%. No death was due to device removal. All deaths were the result of severe preoperative and continuing postextraction sepsis. Conclusions A lead extraction protocol that included procedures done in an operating room environment allowing rapid, open intervention for bleeding, a varied choice of extraction tools, arterial line monitoring, transesophageal echocardiography, general anesthesia, and an experienced team yielded complete extraction in more than 90% of patients, with a low complication rate and no procedurally related deaths.

Background We evaluated all adult St. Jude mechanical valve recipients at our institution since the initial implant in January 1979 and now present our 25-year experience. Methods Nine hundred forty-five valve recipients were followed prospectively at 12-month intervals from January 1979 to December 2007. Results Operative mortality was 3% in the aortic valve recipients and 5% in the mitral valve recipients. Follow-up was 95% complete. Among aortic valve recipients, late actuarial survival was 81% ± 2%, 59% ± 2%, 41% ± 3%, 28% ± 3%, and 17% ± 4% at 5, 10, 15, 20, and 25 years, respectively. Twenty-five–year freedom from reoperation, thromboembolism, bleeding, and endocarditis was 90% ± 2%, 69% ± 5%, 67% ± 3%, and 9% 3 ± 2% respectively. Among mitral valve recipients late actuarial survival was 84% ± 2%, 63% ± 3%, 44% ± 3%, 31% ± 3%, and 23% ± 4% at 5, 10, 15, 20, and 25 years, respectively. Twenty-five–year freedom from reoperation, thromboembolism, bleeding and endocarditis was 81% ± 10%, 52% ± 8%, 64% ± 6%, and 97% ± 1%. Freedom from valve-related mortality and morbidity at 25 years was 26% ± 7% and 29% ± 6% for aortic and mitral valve replacement, respectively. Freedom from valve-related mortality was 66% ± 8% and 87% ± 3% for aortic and mitral valve replacement, respectively. Conclusions These results compare favorably with those for other mechanical prostheses. After two and a half decades of observation with close follow-up, the St. Jude mechanical valve continues to be a reliable prosthesis.

Complex cardiovascular surgery often results in postoperative hemorrhage. Excessive blood product use may cause systemic thrombosis, end-organ dysfunction, and edema preventing chest closure. Recombinant activated factor VII (rFVIIa) concentrate may decrease hemorrhage where other treatment measures failed. We reviewed our experience with rFVIIa after complex cardiovascular surgery.A retrospective review evaluating 846 complex cardiovascular surgery patients of whom 36 received rFVIIa between January 1, 2001, and December 31, 2006, was performed. Efficacy and safety data were collected for the entire cohort in addition to delayed sternal closure requirements, reoperation, and operative mortality in the patient cohort temporally separated into two groups (pre-rFVIIa era, 2001 to 2003, 1 patient received rFVIIa; rFVIIa era, 2004 to 2006, 35 patients received rFVIIa).A total of 36 patients received 41 rFVIIa doses with an in-hospital survival of 91.7%. Hemorrhage was controlled in 83.3% of patients, with 1 dose sufficient in 75.0%. There was a significant decrease (p0.005) in all blood product requirements post-rFVIIa compared with pre-rFVIIa administration. In the intensive care unit (n = 6), rFVIIa significantly reduced chest tube output (p = 0.028) and prevented reexploration for bleeding in 5 patients. The requirement for delayed sternal closure was significantly higher in the pre-rFVIIa era versus the rFVIIa era (p = 0.011). The incidence of thrombosis in all patients receiving rFVIIa was 11.1%. In the rFVIIa era, a higher incidence of postoperative renal failure (p = 0.005) and pneumonia (p0.002) was detected in patients receiving rFVIIa.Recombinant activated factor VII appears to be effective in patients with refractory coagulopathy undergoing high-risk cardiovascular surgery.

Background Left internal mammary artery spasm is well recognized during coronary artery bypass operations. Papaverine has been used by many surgeons to maximize mammary artery flow perioperatively, but the best delivery method is not known. We analyzed two techniques used at our institution. Methods Fifty-eight patients were randomized into three groups to compare papaverine's ability to prevent spasm and to treat established spasm. Group 1 was control and no treatment was employed. In group 2, papaverine was injected with a blunt needle through the endothoracic fascia parallel to the mammary artery before harvest to assess spasm prevention. In group 3, papaverine was delivered perivascular in an identical manner to group 2 but after the mammary artery was dissected from the chest wall. This group was an evaluation of spasm treatment. Drug dosage was the same for both groups and routine bypass grafting was performed. Before anastomosing the mammary artery to the left anterior descending artery, blood flow was recorded for 15 seconds and flow per minute calculated. Cardiopulmonary bypass pressures were maintained at 70 mm Hg during collection. Results Mean blood flows were: group 1=86.2 mL/min, group 2=122.5 mL/min, and group 3=139.7 mL/min. Left internal mammary artery flow in group 3 was statistically different from control ( p = 0.0457). Group 2 flow approached but did not reach statistical significance ( p = 0.0874). Mammary artery dissection times for the three groups were not different. Conclusions Papaverine delivery to the left internal mammary artery after dissection treats spasm effectively, improves blood flow at the time of its anastamosis to the left anterior descending artery, and avoids any risk of intimal injury. Injection of papaverine before mammary artery harvest does not shorten dissection time, and flow is not statistically improved.

Background . Dialysis patients frequently present with debilitating coronary artery disease but are regarded as challenging patients for coronary artery bypass grafting. Methods . The operative, early postoperative, and late results of 44 dialysis patients undergoing coronary artery bypass grafting from 1984 to 1997 were retrospectively reviewed. Results . Compared with patients in The Society of Thoracic Surgeons database who underwent coronary artery bypass grafting, only cerebrovascular accident and postoperative cardiac arrest occurred more frequently in dialysis patients. However, 73% experienced some type of complication. Operative mortality was 11.4%. Decreased left ventricular ejection fraction and severe distal disease were predictive of increased operative mortality. New York Heart Association angina class fell from 2.8 to 1.5, and New York Heart Association congestive heart failure class fell from 2.6 to 1.8. Overall quality-of-life scores did not improve; however, walking distances remained consistently improved. Actuarial survival at 5 years was 32.0% ± 12.0%. Five-year survival was 0% for smokers and 83.6% ± 7.6% for nonsmokers ( p = 0.0142). Causes of late death were myocardial infarction (4), sepsis (1), subdural hematoma (1), stroke (1), and unknown (6). Conclusions . Coronary artery bypass grafting should be avoided in dialysis patients with severe diffuse disease. A smoking history is associated with poor outcome. Coronary artery bypass grafting in dialysis patients is associated with a higher incidence of complications but can be performed with an acceptable operative mortality and is associated with good symptomatic relief of angina and heart failure.

All patients undergoing St. Jude Medical valve replacement at the Medical University of South Carolina since January 1979 have been followed prospectively at 12-month intervals.This report describes long-term experience in 710 adult patients undergoing isolated aortic (AVR) (418) or mitral valve replacements (MVR) (292) with this prosthesis from January 1979 to December 1996.Ages ranged from 19 to 84 years (54.8 +/- 15.1 AVR, 51.8 +/- 12.9 MVR; mean +/- SD). Male gender predominated in the AVR group (70%) and female gender in the MVR group (62%). One hundred and fifty-seven patients (22%) had associated coronary artery bypass grafting (AVR 27%, MVR 15%). Thirty-day operative mortality was 5.3% (22/418) in the AVR group and 5.1% (15/292) in the MVR group. Follow-up is 96.9% complete and ranges from 1 month to 16.9 years (AVR, 2,376 patient-years, mean 5.7 +/- 4.5 years; MVR, 1,868 patient-years, mean 6.4 +/- 4.8 years). In the AVR group, 120 late deaths have occurred and actuarial survival was 78.0 +/- 2.3%, 58.0 +/- 3.2%, and 36.8 +/- 4.8%; at 5, 10, and 15 years, respectively. Forty-six patients have sustained 55 thromboembolic (TE) events (2.3%/patient-year). Fifty-one patients had anticoagulant-related bleeding complications (2.7%/patient-year). The mean improvement in New York Heart Association (NYHA) functional class from preoperative to postoperative was 3.0 +/- 0.8 to 1.7 +/- 0.1 (p0.05). In the MVR group, there have been 84 late deaths, and the actuarial survival was 79.3 +/- 2.5%, 60.1 +/- 3.5%, and 49.3 +/- 4.1% at 5, 10, and 15 years, respectively. Fifty-two patients have had 64 TE events (3.5%/patient-year). Twenty-three patients had anticoagulant-related bleeding complications (1.6%/patient-year). The mean improvement in NYHA functional class was from 3.3 +/- 0.6 to 1.8 +/- 0.1. There were no mechanical failures in either group.With a follow-up now extending to 17 years, the St. Jude Medical valve continues to be a reliable mechanical prosthesis with low and stable rates of valve-related complications.

We reviewed our 12-year experience with 254 adult patients who had St. Jude valves in the aortic position and used multivariate analysis to examine risk factors possibly affecting long-term morbidity and mortality. Nineteen-millimeter or 21-mm valves were implanted in 115 patients. Poor preoperative congestive heart failure status was associated with persistent congestive heart failure on late foliow-up. Preoperative congestive heart failure and coronary artery disease were the only predictors of overall late death. Late deaths associated with heart failure and late sudden deaths were examined separately. Preoperative degree of heart failure was the only predictor of late death with associated heart failure. The implantation of a 19- or 21-mm valve in patients with a body surface area greater than 1.9 m 2 somewhat increased the risk of late sudden death. In patients with a body surface area greater than 1.9 m 2 and with a 19-mm or 21-mm annulus, consideration should be given to using a high-performance St. Jude valve or performing an annulus-enlarging procedure if this can be done with negligible morbidity.

From January 1, 1979 through December 1990, 456 adult patients underwent isolated aortic (AVR) (254) or mitral (MVR) (202) valve replacement with the St. Jude prosthesis at the Medical University of South Carolina. Age ranged from 21 to 84 years (mean: 54 +/- 15 years for AVR; 51 +/- 13 years for MVR). Male sex predominated in the AVR group (66%) and female sex in the MVR group (64%). Ninety-two patients (20%) had associated coronary artery bypass grafting (AVR, 25%; MVR, 14%). There were 17 deaths (3.7%) occurring during the same hospitalization or within 30 days (AVR, 10/254 [3.9%]; MVR, 7/202 [3.5%]). Follow-up is 94.5% complete and ranges from 1.0 to 131 months (mean, 55 +/- 37 months; total, 2,073 patient-years). In the AVR group, 53 late deaths have occurred and actuarial survival is 80% +/- 3% at 5 years and 47% +/- 9% at 10 years. Twenty-one patients have sustained thromboembolic episodes (1.8%/patient-year), and the probability of remaining free of thromboembolism at 10 years is 67% +/- 13%. The mean improvement in New York Heart Association functional class from preoperative to postoperative is 3.1 +/- 0.76 to 1.6 +/- 0.84 (p < 0.0001). In the MVR group, there have been 41 late deaths, and the actuarial survival was 80% +/- 3% at 5 years and 63% +/- 5% at 10 years. Twenty-eight patients have sustained thromboembolic complications (2.9%/patient-year), and the probability of remaining free of thromboembolism at 10 years is 77% +/- 5%.(ABSTRACT TRUNCATED AT 250 WORDS)

We have attempted to optimize cardiac performance in patients with congenital heart disease requiring artificial pacing by using pacemakers capable of both sensing and pacing both the atrium and the ventricle (DDD). We reviewed our results with 88 patients receiving DDD devices to determine the safety and dependability of these devices in children. Age ranged from 1 hour to 25 years. Endocardial leads were used in 68 patients, whereas epicardial leads were used in 20 patients. Previous cardiac procedures had been done in 30 patients. There were nine deaths but none due to pacemaker malfunction. Endocardial leads functioned better than epicardial leads. Ninety-eight percent of patients with endocardial leads and 62% of patients with epicardial leads were maintained in the DDD mode. Complications were infrequent and all were corrected without long-term sequelae. The DDD mode may offer considerable benefits to children who require artificial pacing. Our data allow us to conclude that most children can be paced safely and dependably in the DDD mode.

To evaluate the best method of palliation for obstructing nonresectable squamous cell carcinoma of the mid or distal esophagus, 27 patients were prospectively randomized to one of three treatment arms: (1) esophageal intubation with an Atkinson tube (AT, 10 patients), (2) esophageal intubation followed by radiation therapy (AT/RT, 8 patients), and (3) endoscopic laser therapy followed by irradiation (L/RT, 9 patients). Pretreatment characteristics were similar in the three groups. There was no procedure-related mortality. There were eight total complications related to the tube and none related to laser treatment (p = 0.02). Mean survival was 119 days in the AT group, 72 days in the AT/RT group, and 169 days in the L/RT arm (p = not significant). Quality of survival was most dependent on swallowing ability, and the swallowing score increased by 2.3 units in the AT group, 1.8 units in the AT/RT group, and 1.4 units in the L/RT group (p = not significant). Adding RT to laser therapy significantly increased time in treatment (mean, 38.7 days) when compared with the AT group (mean, 12.5 days) (p less than 0.001). However, only 1 patient required repeat laser ablation. It is concluded that AT and L/RT result in good palliation as measured by relief of dysphagia and survival time. However, morbidity of AT is significantly greater than that of L/RT. Laser and radiation therapy with a reduced total dosage of RT or with a change in fractionation schedule to limit treatment time is the preferred method of palliation.

Background . A number of cellular and molecular events can be induced after cardiac procedures requiring cardiopulmonary bypass (CPB). The matrix metalloproteinases (MMPs) are a recently discovered family of enzymes that degrade the extracellular matrix, but expression during and after CPB is unknown. Methods . Systemic plasma MMP levels were measured in patients (n = 28, 63 ± 1 years) undergoing elective coronary revascularization requiring CPB at baseline, termination of CPB, and 30 minutes, 6 and 24 hours after CPB. Representative classes of MMP species known to degrade matrix and basement membrane components were selected for study. Specifically, the interstitial collagenases MMP-8 and MMP-13, and the gelatinases MMP-2 and MMP-9 were determined by internally validated enzyme-linked immunosorbent assay. Results . The MMP-8 levels increased by fourfold at separation from CPB, and returned to within normal values within 30 minutes after CPB. The proenzyme forms of MMP-13 and MMP-9 increased by more than twofold at cross-clamp release and returned within normal limits within 6 hours after CPB. The proform of MMP-2 increased from baseline values at 6 and 24 hours postoperatively; likely indicative of de novo synthesis. Conclusions . A specific portfolio of MMPs are released and synthesized during and after CPB. Because MMPs can degrade extracellular proteins essential for maintaining normal cellular architecture and function, enhanced MMP release and activation may contribute to alterations in tissue homeostasis in the early postoperative period.

Radial artery (RA) is being used for coronary artery bypass grafting (CABG) with greater frequency. However, RA is prone to post-CABG vasospasm, which may be neurohormonally mediated. Use of the calcium channel antagonist diltiazem has been advocated as a strategy to reduce post-CABG RA vasospasm. However, whether and to what degree different calcium channel antagonists influence neurohormonally induced RA vasoconstriction remains unknown.RA segments were collected from patients undergoing elective CABG (n = 13), and isometric tension was examined in the presence of endothelin (10 nM) or norepinephrine (1 microM). In matched RA, endothelin- or norepinephrine-induced contractions were measured in the presence of diltiazem (277 nM), amlodipine (73 nM), or nifedipine (145 nM). These concentrations of calcium channel antagonists were based upon clinical plasma profiles.Endothelin and norepinephrine caused a significant increase in RA-developed tension (0.54+/-0.1 and 0.68+/-0.1 g/mg, respectively; p0.05). Amlodipine or nifedipine significantly reduced RA vasoconstriction in the presence of endothelin (30+/-6% and 41+/-9%, respectively; p0.05) or norepinephrine (27+/-8% and 53+/-9%, respectively; p0.05), whereas diltiazem did not significantly reduce RA vasoconstriction.These results demonstrate that neurohormonal factors released post-CABG can cause RA vasoconstriction, and that calcium channel antagonists are not equally effective in abrogating that response. Both amlodipine and nifedipine, which have a higher degree of vascular selectivity, appear to be the most effective in reducing RA vasoconstriction.

The return of extracorporeal circuit blood at the termination of cardiopulmonary bypass is an important feature of blood conservation during open heart procedures. However, the relative benefits and disadvantages of different circuit blood salvage methods remain unclear. Accordingly, the purpose of this study was to examine whether quantifiable differences exist between three different circuit blood-salvaging techniques: direct infusion, centrifugation, and ultrafiltration. Sixty patients with very similar preoperative characteristics were randomly assigned to each of the three groups, and blood coagulation screens, plasma profiles, and respiratory function were determined at 20 minutes and at 6 and 18 hours after cardiopulmonary bypass. Early after cardiopulmonary bypass (20 minutes), the plasma colloid osmotic pressure and fibrinogen and platelet concentrations were significantly higher with ultrafiltration (p < 0.05) versus those observed for the other two methods. The plasma thromboplastin times were significantly (p < 0.05) longer after cardiopulmonary bypass with centrifugation as compared to direct infusion and ultrafiltration. However, the coagulation profiles and plasma composition normalized by 18 hours after cardiopulmonary bypass with all three blood-salvaging methods. There were no significant differences in terms of blood utilization or chest tube drainage over the entire postoperative period among any of the circuit blood-salvaging methods. These results suggest that ultrafiltration of postcardiopulmonary circuit blood may preserve plasma colloid pressure and platelet concentration in the early postoperative period, but these differences do not persist. Thus, for routine cardiopulmonary bypass procedures, direct infusion, centrifugation, and ultrafiltration may all be satisfactory methods of circuit blood salvage.

Retrograde cardioplegia administered through the coronary sinus has several documented advantages over antegrade cardioplegia but has been thought to provide inadequate right ventricular myocardial protection. We prospectively compared the effects of retrograde and antegrade cardioplegia on right ventricular performance in patients undergoing myocardial revascularization. Two groups of similar age, extent of disease, and preoperative left ventricular ejection fraction received retrograde (n = 16) or antegrade (n = 14) crystalloid cardioplegia. A right ventricular rapid-response thermistor catheter, previously developed and validated in our institution, was used to measure right atrial pressure, pulmonary artery pressure, right ventricular ejection fraction, end-diastolic volume index, and stroke volume index before bypass (baseline) and at several intervals after bypass. There were no differences in cross-clamp time, heart rate, cardiac enzymes, inotrope requirements, or arrhythmias between the two groups. Right ventricular parameters were equivalent in both groups at all time intervals except 30 minutes after bypass, at which time right ventricular end-diastolic volume index was lower (80 +/- 6 versus 93 +/- 6 mL/m2; p less than 0.05) and right ventricular stroke volume index was higher (35 +/- 3 versus 29 +/- 2 mL/m2, p less than 0.05) in the retrograde group compared with the antegrade group, indicating better right ventricular function with retrograde cardioplegia early after bypass. In both groups, right ventricular end-diastolic volume index was higher than baseline (p less than 0.05) during the first 4 hours after bypass. No other important differences were found.(ABSTRACT TRUNCATED AT 250 WORDS)

With the advent of tined transvenous cardiac pacing leads, the complets extraction of pacing leads in the treatment of an infected cardiac pacing system has become increasingly difficult. A method is described for the extracticn of permanent pacing leads from the heart using alligator forceps inserted transvenously through the right internal jugular vein, grasping the lead near its insertion point in the cardiac muscle.

The purpose of this report is to record the results of a treatment protocol for patients with carcinoma of the esophagus. In May, 1980, we initiated a program of chemoradiation therapy preliminary to resection in pa- tients in whom the protocol was applicable. The chemo- therapy consisted of mitomycin-C, 10 mg as a bolus intra- venous injection on day 1, and 5-fluorouracil, 1,000 mg per square meter of body surface area in 1,000 ml of 5% glu- cose solution in distilled water given intravenously on each of days 1 through 4. The radiation therapy consisted of 3,000 rads in three weeks using cobalt 60 or 6 MeV or greater, with ports to cover the tumor and mediastinum. This protocol was given to patients with primary carci- noma of the esophagus whose disease remained or became operable during or following the course of the chemoradia- tion. Among the patients treated according to the protocol, the operability rate was increased. The resectability rate re- mained about the same as in our previous experience. The operative mortality was lessened appreciably. The percent- age of resected specimens of the esophagus showing resid- ual tumor decreased. However, the absence of any residual tumor in the surgical specimen has not conferred any im- proved chance of long-term survival to date. There has been a two-year survival of 33% (7/21) among the small group having chemoradiation therapy prior to resection, and this figure is roughly the same as that in our previ- ously reported series of patients treated by preoperative irradiation (4,500 rads in three weeks) and resection with- out the chemotherapeutic adjunct. The observations are short term, but 12 of 31 patients (39%) having chemoradia- tion therapy followed by resection are still alive. This may be an encouraging portent.

The purpose of this report is to record the results of a treatment protocol for patients with carcinoma of the esophagus. In May, 1980, we initiated a program of chemoradiation therapy preliminary to resection in patients in whom the protocol was applicable. The chemotherapy consisted of mitomycin-C, 10 mg as a bolus intravenous injection on day 1, and 5-fluorouracil, 1,000 mg per square meter of body surface area in 1,000 ml of 5% glucose solution in distilled water given intravenously on each of days 1 through 4. The radiation therapy consisted of 3,000 rads in three weeks using cobalt 60 or 6 MeV or greater, with ports to cover the tumor and mediastinum. This protocol was given to patients with primary carcinoma of the esophagus whose disease remained or became operable during or following the course of the chemoradiation. Among the patients treated according to the protocol, the operability rate was increased. The resectability rate remained about the same as in our previous experience. The operative mortality was lessened appreciably. The percentage of resected specimens of the esophagus showing residual tumor decreased. However, the absence of any residual tumor in the surgical specimen has not conferred any improved chance of long-term survival to date. There has been a two-year survival of 33% (7/21) among the small group having chemoradiation therapy prior to resection, and this figure is roughly the same as that in our previously reported series of patients treated by preoperative irradiation (4,500 rads in three weeks) and resection without the chemotherapeutic adjunct. The observations are short term, but 12 of 31 patients (39%) having chemoradiation therapy followed by resection are still alive. This may be an encouraging portent.

Unexpected involvement of the superior vena cava with dense inflammatory and fibrous tissue was encountered during right pneumonectomy for a T3 N0 M0 squamous cell carcinoma. After expeditiously completing the lung resection, the azygos vein was utilized for a successful superior vena cava bypass.

Temporary external pacemakers have been reported to fail under hyperbaric conditions. In this study we investigated cardiac pacing under hyperbaric conditions. Permanent hermetically sealed pacemakers were found to function well under hyperbaric conditions, while several models of temporary external pacemakers failed. The electrical characteristics of pacing leads did not change under hyperbaric conditions. External pacing under hyperbaric conditions may be accomplished safely by using a permanent pacemaker attached to the patient's temporary external leads.