Search

Background: The purpose of the present study was to determine independent predictors for early and midterm mortality for the whole context of thoracic surgery., Methods: We studied 1453 consecutive patients who underwent thoracic surgery between 2002 and 2005. Operations included lung resections (n = 504), mediastinal (n = 468), pleural and pericardial (n = 226), esophageal (n = 83), chest wall (n = 85), tracheal (n = 50) and other procedures (n = 37). Midterm survival data (mean follow-up 2.0 +/- 1.1 years) were obtained from the National Death Index. Multivariate logistic regression was used to assess in-hospital mortality. Independent predictors for midterm mortality were determined by multivariate Cox regression analysis., Results: There were 47 (3.2 %) in-hospital and 312 (21.5 %) late deaths. Independent predictors for in-hospital mortality included Zubrod score (OR 2.72, P < 0.001), ASA score (OR 3.42, P < 0.001), pneumonectomy (OR 20.71, P = 0.001) and no history of cerebrovascular events (OR 0.27, P = 0.011). Independent predictors for midterm mortality included age (HR 1.03, P < 0.001), weight loss (HR 1.57, P = 0.005), Zubrod score (HR 1.47, P < 0.001), primary lung cancer (HR 1.98 P < 0.001), intrathoracic extrapulmonary metastases (HR 2.78, P < 0.001), primary chest wall tumor (HR 0.14, P = 0.008), diabetes requiring insulin (HR 1.71, P = 0.017), no preoperative renal failure (HR 0.57, P = 0.004), no comorbidities (HR 0.54, P = 0.009), ASA score (HR 1.69, P < 0.001), postoperative radiation treatment (HR 1.90, P = 0.016), pneumonectomy (HR 2.18, P = 0.040), reoperation for bleeding and/or postoperative transfusion (HR 3.10, P = 0.027) and postoperative pulmonary complications (HR 1.89, P = 0.013)., Conclusions: We determined independent predictors for in-hospital and midterm mortality for the whole context of thoracic surgery. Zubrod and ASA scores affect both early and midterm mortality.

Background: Despite appropriate therapy, refractory hypotension often occurs in septic shock. A double-blinded placebo controlled clinical trial was performed to assess the role of low-dose vasopressin (VP) as a pressor agent in septic shock., Methods: Patients admitted to a trauma intensive care unit with vasodilatory septic shock were randomized to receive either VP at 0.04 U/min (n = 5) or placebo (n = 5). Vasodilatory septic shock was defined as a need for catecholamine agents to maintain a mean arterial pressure more than or equal to 70 mm Hg, despite a cardiac index more than 2.5 L/min and a minimal pulmonary artery wedge pressure more than 12 mm Hg. After 1 hour of initiation of the study drug, attempts to discontinue norepinephrine, phenylephrine, and/or dopamine, in respective order, were undertaken provided that the mean arterial pressure remained more than or equal to 70 mm Hg., Results: A vasopressin infusion increased systolic arterial pressure (98 +/- 5 to 125 +/- 8 mm Hg, p < 0.008) because of peripheral vasoconstriction (systemic vascular resistance increased from 878 +/- 218 to 1,190 +/- 213 dynes/s per cm(-5) p < 0.05). Arterial pressure and systemic vascular resistance were statistically unaffected in the placebo group. Before study termination, measured at 24 hours after drug initiation, two patients in the placebo group died of refractory hypotension. However, all patients receiving VP survived the 24-hour study period and had all other catecholamine pressors withdrawn and blood pressure maintained solely with a low-dose VP infusion., Conclusion: A VP infusion improved arterial pressure and permitted the withdrawal of catecholamine vasopressors. VP is a useful agent in the treatment of refractory septic shock.

Objective: The purpose of this study was to quantify the magnitude of interaction between the right and left ventricles in conditions of heart failure., Methods: Human hearts were taken from transplant recipients diagnosed with diluted cardiomyopathy at the time of transplantation and were restored to beating condition with use of an isolated perfusion circuit. Left ventricular-right ventricular interaction was determined by ramping volume in the left ventricle while holding right ventricular volume constant. Right ventricular pressure gain was plotted against left ventricular pressure and the slope of the linear regression determined the left ventricular-right ventricular interaction. A similar procedure was used to determine right ventricular-left ventricular interaction. Two normal hearts were obtained from transplant donors not suitable for cardiac donation to serve as control hearts., Results: Mean left ventricular-right ventricular interaction was 0.22 in the hearts with dilated cardiomyopathy compared with 0.06 in the control hearts. Mean right ventricular-left ventricular interaction was 0.14 in the hearts with dilated cardiomyopathy compared with 0.09 in the control hearts. A marked increase in left ventricular-right ventricular interaction was noted in the hearts with dilated cardiomyopathy compared with control hearts. Although observed values of right ventricular-left ventricular interaction also correspond to previously published results, no significant increase was observed in the dilated cardiomyopathy condition., Conclusions: These studies confirm previously published values for systolic ventricular interaction obtained with animal models and demonstrate a marked increase in the dependence of the right ventricle on left ventricular function to maintain systolic pressure generation during conditions of dilated cardiomyopathy.

Right sided circulatory failure (RSCF), a common complication after left ventricular assist device (LVAD) implantation, results in decreased systemic output due to diminished blood flow across the pulmonary vasculature. The authors hypothesized that creation of a venoarterial shunt (VAS) would decompress the right-sided circulation and improve systemic pressure and perfusion with significant arterial desaturation. An experimental model was created in which RSCF was induced acutely in a large animal (n = 6) by beta-blockade after LVAD placement. After VAS creation, hemodynamic and blood gas determinations were performed to compare non shunt and shunt states. After induction of heart failure after LVAD placement, VAS resulted in a 22% elevation in systemic blood pressure (p < 0.0001), a 36% elevation in cerebral blood flow (p = 0.02), and an 18% decrease in right sided filling pressures (p = 0.08). Systemic pH and aortic oxygen saturation remained unchanged from baseline. In a large animal model of RSCF after LVAD implantation, VAS improves systemic hemodynamics without a significant cost in arterial oxygenation to critical organs and without creating acid-base imbalance. Beside implementation, adjustable capabilities, easy removal and salutatory hemodynamic effects suggest that VAS may serve as a first line, short-term therapy for LVAD recipients who develop perioperative RSCF.

Background: Elevated tumor necrosis factor serum levels have been reported in patients with severe congestive heart failure. This study was designed to characterize the cytokine profile in patients with acute circulatory collapse., Methods: Blood drawn from 14 consecutive patients within 24 hours before undergoing left ventricular assist device placement and after at least 30 days of mechanical assistance or before transplantation was assayed for levels of interleukin 6, interleukin 8, and tumor necrosis factor-alpha., Results: Interleukin 6 level was elevated in 11 (79%), interleukin 8 in 10 (71%), and tumor necrosis factor in 2 (14%) of the 14 patients. After hemodynamic recovery, interleukin 6 levels decreased from 33.6 +/- 9 pg/mL to 11.3 +/- 4 pg/mL (p = 0.05) and interleukin 8 levels decreased from 122 +/- 34 pg/mL to 19.7 +/- 8 pg/mL (p = 0.005). Tumor necrosis factor-alpha levels did not vary significantly; they were associated with infection in 2 left ventricular assist device recipients and normalized after left ventricular assist device support. All patients had resolution of circulatory shock after mechanical support and had improvement in parameters of end-organ function., Conclusions: Circulatory shock treated with left ventricular assist device placement is associated with a proinflammatory response similar to that seen in septic shock. The decrease in cytokine serum levels that follows hemodynamic recovery suggests that these cytokines may be markers of tissue damage and may modulate cardiac dysfunction.

Background: If long-term use of left ventricular assist devices (LVADs) as bridges to transplantation is successful, the issue of permanent device implantation in lieu of transplantation could be addressed through the creation of appropriately designed trials. Our medium-term experience with both pneumatically and electrically powered ThermoCardiosystems LVADs is presented to outline the benefits and limitations of device support in lieu of transplantation., Methods and Results: Detailed records were kept prospectively for all patients undergoing LVAD insertion. Fifty-eight LVADs were inserted over 5 years, with a survival rate of 74%. Mean patient age was 50 years, and duration of support averaged 98 days. Although common, both preexisting infection and infection during LVAD support were not associated with increased mortality or decreased rate of successful transplantation. Thromboembolic complications were rare, occurring in only three patients (5%) despite the absence of anticoagulation. Ventricular arrhythmias were well tolerated in all patients except in cases of early perioperative right ventricular failure, with no deaths. Right ventricular failure occurred in one third of patients and was managed in a small percentage by right ventricular assist device (RVAD) support and/or inhaled nitric oxide therapy. There were no serious device malfunctions, but five graft-related hemorrhages resulted in two deaths. Finally, a variety of noncardiac surgical procedures were performed in LVAD recipients, with no major morbidity and mortality., Conclusions: Over all, our medium-term experience with implantable LVAD support is encouraging. Although additional areas of investigation exist, improvements in patients selection and management together with device alterations that have reduced the thromboembolic incidence and facilitated patient rehabilitation lead us to believe that a prospective, randomized trial is indicated to study the role that LVADs may have as an alternative to medical management.

Background: The hypotension of septic shock is due to systemic vasodilation. On the basis of a clinical observation, we investigated the possibility that a deficiency in vasopressin contributes to the vasodilation of septic shock., Methods and Results: In 19 patients with vasodilatory septic shock (systolic arterial pressure [SAP] of 92 +/- 2 mm Hg [mean +/- SE], cardiac output [CO] of 6.8 +/- 0.7 L/min) who were receiving catecholamines, plasma vasopressin averaged 3.1 +/- 1.0 pg/mL. In 12 patients with cardiogenic shock (SAP, 99 +/- 7 mm Hg; CO, 3.5 +/- 0.9 L/min) who were also receiving catecholamines, it averaged 22.7 +/- 2.2 pg/mL (P < .001). A constant infusion of exogenous vasopressin to 2 patients with septic shock resulted in the expected plasma concentration, indicating that catabolism of vasopressin is not increased in this condition. Although vasopressin is a weak pressor in normal subjects, its administration at 0.04 U/min to 10 patients with septic shock who were receiving catecholamines increased arterial pressure (systolic/diastolic) from 92/52 to 146/66 mm Hg (P < .001/P < .05) due to peripheral vasoconstriction (systemic vascular resistance increased from 644 to 1187 dyne.s/cm5; P < .001). Furthermore, in 6 patients with septic shock who were receiving vasopressin as the sole pressor, vasopressin withdrawal resulted in hypotension (SAP, 83 +/- 3 mm Hg), and vasopressin administration at 0.01 U/min, which resulted in a plasma concentration (approximately 30 pg/mL) expected for the level of hypotension, increased SAP from 83 to 115 mm Hg (P < .01)., Conclusions: Vasopressin plasma levels are inappropriately low in vasodilatory shock, most likely because of impaired baroreflex-mediated secretion. The deficiency in vasopressin contributes to the hypotension of vasodilatory septic shock.

Background: Left ventricular assist devices have become an important tool in the successful treatment of heart failure as bridges to transplantation. The optimal duration of device support before heart transplantation is debated. We report the effect of left ventricular device support duration on survival after heart transplantation., Methods: All patients bridged to heart transplantation with the ThermoCardiosystems Heartmate 1,000 IP left ventricular assist device between January 1, 1986, and October 15, 1994, were included in our study. Parameters studied included duration of support, measures of end-organ function, and complications while supported with the device. Patients supported < 30 days were compared with patients supported > 30 days before undergoing transplantation., Results: Patients supported for < 30 days had a threefold increased perioperative mortality compared with patients supported > 30 days (p = 0.031). Laboratory values of end-organ function were similar before left ventricular device insertion in both groups, although at the time of transplantation patients supported < 30 days had a significantly elevated bilirubin level compared with patients supported > 30 days (p < 0.001). Patients supported > 30 days had significantly more infections than the < 30 days group (p = 0.0345)., Conclusions: Patients supported for > 30 days with left ventricular assist devices have improved post-transplant perioperative survival because of normalization of end-organ function and improved physiologic status secondary to aggressive physical rehabilitation. Patients should be supported for > 30 days in combination with physical rehabilitation, to improve early survival after heart transplantation.

Objectives: Development of an intraluminal device to reduce aortic regurgitation could provide a strategy intermediate between medical treatment and aortic valve replacement. An initial prototype and a testing system have been designed., Methods: Aortic valves obtained from heart transplant recipients were explanted and assessed in a mock circulatory loop with resistive and capacitive elements, including pressure-flow characteristics, similar to those of a normal arterial system. Normal heart function was simulated by a pulsatile ventricular-assist device. Pressure on each side of the valve and flow through the valve were recorded, allowing the calculation of regurgitant fractions and transvalvular gradients. Six solid geometrically differing obturators were tested., Results: All six designs resulted in significant reduction in aortic regurgitation (p < 0.0001), ranging from 15% to 38% improvement compared with control values. Small increases in transvalvular gradients (from 0 to 7 mm Hg) were also noted., Discussion: Initial results suggest that an intraluminally placed obturator can reduce aortic regurgitation without creating clinically significant transvalvular gradients. These initial in vitro experiments demonstrate the feasibility of an intraluminal device for the treatment of aortic valve disease, and further investigation is warranted.

Background: The Frank-Starling mechanism is one of the most important physiological principles for regulation of contractile performance. We therefore studied the question of whether this mechanism may be absent or attenuated in end-stage failing human left ventricular myocardium., Methods and Results: Different methodological approaches were used to analyze the effects of this mechanism on the organ, tissue, and sarcomere levels: (1) In excised human whole left ventricles (2 donor hearts, 5 failing hearts), diastolic and systolic pressure-volume relationships were obtained. (2) In isolated muscle strip preparations from the left ventricular wall of donor hearts (n = 14) and failing hearts from patients with idiopathic dilated cardiomyopathy (n = 21) and ischemic cardiomyopathy (n = 11), peak developed force was measured at different muscle lengths of the preparation. (3) Skinned fiber preparations were obtained from failing right and left ventricles (n = 12). In all three studies, we clearly observed the existence of the Frank-Starling mechanism: (1) In isolated failing human left ventricles, peak developed isometric pressure is increased when the preload is elevated. (2) Peak developed tension is increased by approximately 50% to 70% (P < .01) in left ventricular preparations of failing and nonfailing ventricles when the muscles are stretched from 90% to 100% optimum length. (3) An increase in sarcomere length leads to a sensitization of contractile proteins of ventricular skinned fiber preparations from failing human hearts. At 1.9-microns sarcomere length, the EC50 value was 5.56 +/- 0.06, and at 2.3 microns it was 5.70 +/- 0.05 (P < .01; n = 7)., Conclusions: The Frank-Starling mechanism is maintained in end-stage failing human hearts, whereas significant alterations of diastolic myocardial distensibility are evident in chronic heart failure.

The authors reviewed the charts of 26 recipients of a left ventricular assist device to determine the incidence of fungal infections and the clinical course of these patients. Nine patients (35%) had positive fungal cultures. Of these, six had clinical infections and three were colonized asymptomatically. Three of the six infected patients (including one with mediastinal sepsis and another requiring left ventricular assist device replacement for intractable fungemia) underwent orthotopic heart transplantation after successful therapy. Of the remaining three, one died of a thromboembolic stroke (probably septic in nature), one died secondary to driveline rupture, and the third succumbed to culture-negative sepsis. Two of the colonized patients underwent transplantation, and the third succumbed to perioperative right sided circulatory failure and hypoxia. Positive fungal cultures were a common finding in our series. Because of a significant incidence of fungal infection-related morbidity, the authors revised their pre operative and post operative protocol to include: 1) 2 weeks of fluconazole therapy (200 mg intravenously daily) for patients receiving broad spectrum antibiotics and for those with evidence of preoperative fungal colonization; 2) daily dressing changes around drivelines; 3) daily nystatin swish and swallow; and 4) empiric fluconazole treatment for culture-negative sepsis. Using this protocol, three left ventricular assist device recipients received prophylactic fluconazole and had no evidence of fungal morbidity or mortality on short-term follow-up.

Background: Right-sided circulatory failure, a complication of heart transplantation and left ventricular assist device use, results in decreased cardiac output due to diminished flow across the pulmonary circuit. We hypothesized that creation of a controlled right-to-left shunt would result in decompression of the right ventricle and improved systemic cardiac output at tolerable oxygen saturations. We also hypothesized that a peripheral veno-arterial shunt is physiologically superior to a central shunt., Methods: Right atrial-femoral artery and right atrial-left atrial shunts were created in a large animal model (calf). Right-sided circulatory failure was induced by banding the pulmonary artery. Hemodynamic measures and blood gas determinations were obtained during nonshunted and shunted states., Results: Peripheral and central shunts resulted in decreased right-sided pressures and increased cardiac output. Arterial oxygen saturation remained greater than 90% during shunting. The peripheral shunt had the added advantage of decreasing left ventricular end-diastolic pressure and left ventricular stroke work., Conclusions: A controlled right-to-left shunt improved hemodynamics and cardiac output in a large animal model with right-sided circulatory failure. This strategy may be useful in the management of transplant and left ventricular assist device recipients with perioperative right-sided circulatory failure. Our studies also indicate that creation of a peripheral shunt has both physiologic and technical advantages over a central shunt.

The effects of complementary techniques and alternative medicine on allopathic therapies is generating much interest and research. To properly evaluate these techniques, well controlled studies are needed to corroborate the findings espoused by individuals practicing complementary medicine therapies. To this end, we evaluated the role of one of these therapies, self-hypnosis relaxation techniques, in a prospective, randomized trial to study its effects on quality of life after coronary artery bypass surgery. Subjects were randomized to a control group or a study group. Study group patients were taught self-hypnosis relaxation techniques the night prior to surgery. The control group received no such treatment. Patients then underwent routine cardiac management and care. The main endpoint of our study was quality of life, assessed by the Profile of Moods Scale. Results demonstrated that patients undergoing self-hypnosis the night prior to coronary artery bypass surgery were significantly more relaxed than the control group (p = 0.0317). Trends toward improvement were also noted in depression, anger, and fatigue. This study demonstrates the beneficial effects of self-hypnosis relaxation techniques on coronary surgery. This study also identifies endpoints and a study design that can be used to assess complementary medicine therapies. Results of this preliminary investigation are encouraging and demonstrate a need for further well-controlled studies.

Objective: The authors describe their experience with left ventricular assist-device (LVAD) recipients undergoing noncardiac surgery and delineate surgical, anesthetic, and logistic factors important in the successful intraoperative management of these patients., Summary Background Data: Left ventricular assist-devices have become part of the armamentarium in the treatment of end-stage heart failure. As the numbers of patients chronically supported with long-term implantable devices grows, general surgical problems that are commonly seen in other hospitalized patients are becoming manifest. Of particular interest is the intraoperative management of patients undergoing elective noncardiac surgical procedures., Methods: The anesthesia records and clinical charts were reviewed for eight ventricular assist-device recipients undergoing general surgical procedures between August 1, 1990 and August 31, 1994., Results: A total of 12 procedures were performed in 6 men and 2 women averaging 52.7 years of age. Mean time elapsed from device implantation to operation was 68 +/- 35 days. Conventional inhalational and intravenous anesthetic techniques were well tolerated in these patients undergoing diverse surgical procedures. No perioperative mortality was observed. Five of eight patients went on to successful cardiac transplantation., Conclusions: Hemodynamic recovery after LVAD insertion has defined a new group of patients who develop noncardiac surgical problems often seen in other critically ill patients. Recognition of the unique potential problems that the LVAD recipient may encounter in the perioperative period--in particular patient positioning, device limitations, and fluid and inotropic management--will ensure an optimal surgical outcome for LVAD recipients undergoing noncardiac surgery.

Left ventricular assist devices can be successfully used in the pediatric population if currently available devices are used appropriately. To highlight their management strategies, the authors' experience with pediatric left ventricular assist devices is reviewed, with case studies documenting options for device use. A retrospective study was conducted for all patients supported at the authors' institutions. Nine pediatric patients received devices during this time, with ages ranging from 12 days to 15 years. There was considerable size differences in our patients, with weights ranging between 2.5 and 73 kg. Either the Abiomed BVS 5000 (Abiomed Cardiovascular, Inc, Danvers, MA) or the Biomedicus centrifugal pump (Bio-Medicus, Inc, Eden Prairie, MN) were used for all patients. Patients were supported for an average of 5 days (range 1-11 days). Eight patients were successfully weaned from the device, with four undergoing transplant. Four patients were discharged and are long-term survivors, and one is still recovering post transplant. Neurologic sequelae were the most common complications in these patients, with four patients having events. Pediatric ventricular assist devices are limited because of size considerations, although current devices can be successfully used for bridging to recovery or transplantation. New devices are needed to meet the flow and size characteristics for pediatric patients. Successful use of assist devices, as has been recognized in adults, is possible in pediatric patients if these requirements are met.

To evaluate the effect of laser-assisted fibrinogen bonding on the tensile strength of suture material, 10 types of sutures were exposed to various time intervals of diode laser energy after pretreatment with dye-enhanced fibrinogen solder. After exposure, each suture material was stressed on a tensometer and compared with nonlased suture material. Our results indicate that polytetrafluoroethylene suture material was virtually unaffected at all time intervals of exposure to laser energy. Polyester suture material retained 64.3% of its tensile strength at 60 sec of exposure to laser energy. White silk suture material maintained 80% of its initial tensile strength at 60 sec of exposure. These suture materials may be used safely in conjunction with laser-assisted fibrinogen bonding even if prolonged laser exposure is necessary. The other suture materials tested may be compromised significantly by prolonged exposure to laser energy and must be used with relatively shorter irradiation periods.

The effect of laser-assisted fibrinogen bonding (LAFB) on the development of intimal hyperplasia was studied with stress-strain profiles and histologic evaluation of canine arteriovenous fistulas (AVFs). In 19 animals femoral AVFs were created with an 808 nm diode laser after topical application of fibrinogen mixed with indocyanine green dye; in the contralateral limb a sutured AVF was created. The animals were divided into three groups. Group 1 dogs (n = 6) were killed serially up to 4 weeks after surgery to examine the healing of the anastomoses created with LAFB. Group 2 dogs (n = 6) were killed 1 month after surgery, and the fresh specimens were strained axially to produce a stress-strain profile graph. Group 3 dogs (n = 7) were killed 7 months after surgery, and the AVFs were infused with formalin under pressure and histologically prepared to allow comparison of the ratio of maximum to minimum intimal hypertrophy. Fibrinogen used for LAFB was resorbed during the first month after operation without evidence of foreign body reaction or inflammation. Tensile break force was not significantly different in the laser-bonded group (4.6 +/- 2.4 pounds) and the sutured group (4.3 +/- 1.7 pounds). The modulus (tensile break force per square inch), a measure of elasticity, identified the laser-bonded AVF (149 +/- 44 pounds per square inch) to be less rigid than the sutured AVF (203 +/- 35 pounds per square inch) (p less than 0.05). No significant differences in the degree of intimal hyperplasia were noted in any area of the anastomoses. Use of LAFB neither accelerates nor prevents intimal hyperplasia in a canine AVF model.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of the stress-strain profiles of welded tissue would provide an additional means of analyzing this new technology and comparing it with alternative anastomosing techniques. Rabbit longitudinal aortotomies were repaired with either 7-O polypropylene sutures or an 808-nm diode laser (power density, 4.8 watts/cm2) after topical application of fibrinogen mixed with indocyanine green dye (peak absorption, 805 nm). The rabbits were sacrificed between 0 and 28 days, and the fresh aortic specimens were strained axially in diluted plasma solution until ultimate breakage occurred in order to produce a stress-strain profile graph. No significant differences were noted between sutured and bonded aorta at any time interval. Nonincised aortic tissue (378 lb/in2) withstood significantly higher stress (P less than 0.05) than both sutured (257 lb/in2) and bonded (210 lb/in2) groups at the time of creation. By 7 days after operation, however, no significant differences were noted among any of the three groups. At 28 days after operation, the laser-bonded aorta was significantly stronger than the control aorta (P less than 0.05). The only significant difference in modulus (stretchability) identified the sutured aorta (373 lb/in2) to be more rigid than the control aorta (231 lb/in2) (P less than 0.05). Both sutured and laser-bonded anastomoses are weaker than control aorta initially; however, after an early critical period, both treatments achieve the strength of control aorta. By 1 month postoperatively, sutured anastomoses have the disadvantage of being less distensible.

From 1980 to 1988, 30 patients from a total population of 123 recipients of sutureless grafts (24%) have required aortic reconstruction with a composite ringed graft. Replacement of the ascending aorta was required in 12 patients, of the aortic arch in six patients, of the descending aorta in two patients, of the thoracoabdominal aorta in two patients, and of the abdominal aorta in eight patients. Eight patients (27%) needed an emergency operation at the time of admission. No patients had permanent neurologic or renal deficits. There was no evidence of pseudoaneurysm formation, graft erosion, graft migration, or aortic bleeding in the postoperative period. Two operative deaths (7%) occurred, both in patients undergoing arch reconstruction. Composite grafts can be created that vary in length and shape, incorporate different graft materials, and accommodate the aorta and its branches. The ability to modify the sutureless prosthesis to suit the disease encountered at operation allows the quickest repair with the least chance of anastomotic complication.

Complications after aortic replacement that result from prolonged graft insertion time and technical difficulties with suturing through friable, diseased aortic tissue can be addressed with use of the sutureless intraluminal ring graft. Between 1978 and 1989, we replaced the ascending aorta or aortic arch with this device in 49 patients. At no time were we unable to use a sutureless graft during a procedure. Twenty-eight cases of aneurysmal disease and 21 cases of acute or chronic dissection were treated. Twenty-six patients required replacement of the aortic valve, with annuloartic ectasia being the most common indication (71%). Ten patients underwent concomitant coronary artery bypass grafting. The operative mortality rate for ascending aortic aneurysm repairs was 4%, and that for dissections was 18%. Five of 8 patients requiring aortic arch replacement survived. Most patients were studied angiographically before discharge. No complications were related to anastomotic hemorrhage, pseudoaneurysm formation, graft migration, or thromboemboli. Individual cases of phrenic nerve palsy, acute tubular necrosis, and transient ischemic attack, all of which resolved completely, were identified. The actuarial 5-year survival rate is 64%. We conclude that modification of the sutureless intraluminal ring graft to suit the pathology encountered at operation allows the quickest repair with the least chance of anastomotic complication.

Use of the intraluminal sutureless ringed prosthesis can reduce graft insertion time and avoid difficulties inherent in suturing to friable, diseased aortic tissue. Since 1976 this device has been inserted into the descending thoracic or thoracoabdominal aorta in 42 procedures for aortic dissection and for aneurysmal disease. The operative mortality rate for descending thoracic aortic dissection repair was 14% and that for descending thoracic aortic aneurysm repair was 8%, with an overall mortality rate of 10%. All three of the patients undergoing thoracoabdominal aortic replacement survived. The mean cross-clamp time for sutureless tube graft insertion was 9 minutes. The average blood replacement was 2.4 units/patient. No patient suffered serious neurologic or renal impairment. A single nonfatal case of graft dislodgement occurred after placement. No evidence of hemolysis, pseudoaneurysm formation, graft erosion, graft migration, or anastomotic bleeding was present in any of the remaining patients. Modification of the sutureless intraluminal device to suit the pathologic condition encountered at operation allows rapid repair with a low incidence of anastomotic complication.

To evaluate our experience with sutureless intraluminal ringed grafts in the abdominal aorta, we reviewed all patients who were managed with this device from 1980 to 1987. Thirty-one patients were identified with a mean follow-up time of 41 months. Three patients had suprarenal aneurysms and four had ruptured abdominal aneurysms. Average tube graft insertion time was 17 minutes and required 0.9 units of transfused blood. There were two postoperative deaths (6 percent), both secondary to myocardial infarction. None of the patients with ruptured or suprarenal aneurysms died. No patients had permanent renal or neurologic deficits, and no instances of postoperative bleeding, wound infection, pseudoaneurysm formation, or graft migration were encountered. The sutureless intraluminal graft can be implanted easily and quickly and is safe for use in the abdominal aorta. It is particularly helpful in the management of suprarenal or ruptured abdominal aneurysms, in which speed is important, and in effecting technically difficult anastomoses to friable aortic tissue.