Faculty Bibliography

Retrograde aortic dissections can be a complication of vascular procedures. We describe a case of an inadvertent cannulation of the right common carotid artery during an attempt at inserting a pulmonary artery catheter. This resulted in dissection of the right common carotid, subclavian, and innominate arteries. Transesophageal echocardiography was able to visualize a retrograde dissection extending back into the ascending aorta

OBJECTIVE: This experiment examined the feasibility of minimally invasive port-access mitral valve replacement via a 2.5 cm incision. METHODS: The study evaluated valvular performance and myocardial functional recovery in six mongrel dogs after port-access mitral valve replacement with a St. Jude Medical prosthesis (St. Jude Medical, Inc., St. Paul, Minn.). Femoro-femoral cardiopulmonary bypass and a balloon catheter system for myocardial protection with cardioplegic arrest (Heartport, Inc., Redwood City, Calif.) were used. The mitral valve was replaced through a 2.5 cm port in the left side of the chest, and the animals were weaned from bypass. Cardiac function was measured before and at 30 and 60 minutes after bypass. Left ventricular pressure and electrical conductance volume were used to calculate changes in load-independent indexes of ventricular function. RESULTS: Each procedure was successfully completed. Recovery of left ventricular function was excellent at 30 and 60 minutes after bypass compared with the prebypass values for elastance (30 minutes = 4.04 +/- 0.97 and 60 minutes = 4.27 +/- 0.57 vs prebypass = 4.45 +/- 0.96; p = 0.51) and for preload recruitable stroke work (30 minutes = 76.23 +/- 4.80 and 60 minutes = 71.21 +/- 2.99 vs prebypass = 71.23 +/- 3.75; p = 0.45). Preload recruitable work area remained at 96% and 85% of baseline at 30 and 60 minutes (p = not significant). In addition, transesophageal echocardiography demonstrated normal prosthetic valve function, as well as normal regional and global ventricular wall motion. Autopsy revealed secure annular-sewing apposition and normal leaflet motion. CONCLUSIONS: These results suggest that minimally invasive mitral valve replacement using percutaneous cardiopulmonary bypass with cardioplegic arrest is technically reproducible, achieves normal valve placement, and results in complete cardiac functional recovery. Minimally invasive mitral valve replacement is now feasible, and clinical trials are indicated

The purpose of this study was to evaluate the effect of sequential external counterpulsation (SECP) on cerebral and renal blood flow. The effect of SECP on carotid and renal artery blood flow was studied in 35 and 18 patients, respectively. With a portable unit, cuffs were applied to the calves and thighs, sequentially inflated with air at the onset of diastole, and deflated at the onset of systole. Carotid and renal artery Duplex studies were performed during intermittent SECP. Flow velocity and flow velocity integral were measured at baseline and during SECP. Diastolic augmentation of carotid and renal artery flow velocity was observed in all patients. The mean carotid flow velocity integral increased by 22% from 27.7 +/- 1.8 cm to 33.1 +/- 2.3 cm (P = 0.001). The mean renal artery flow velocity integral increased by 19% from 21 +/- 1 cm to 25 +/- 1 cm (P = 0.0001). With SECP, a new diastolic Doppler flow velocity wave was observed, with an average peak carotid diastolic flow velocity of 56 +/- 4 cm/sec and an average peak renal artery diastolic flow velocity of 40 +/- 2.5 cm/sec. This diastolic wave was 75% (carotid) and 68% (renal) as high as the systolic wave during SECP. In addition, with SECP the systolic wave increased by 6% and 8% in the carotid and renal artery, respectively (P = 0.02 and 0.006, respectively). In conclusion, SECP significantly increases carotid and renal blood flow. This noninvasive, harmless treatment may be useful to support patients with decreased cerebral and renal perfusion

In an 80-year-old patient with syncope, a markedly tortuous descending thoracic aorta produced images on transesophageal echocardiography which were suggestive of an intimal flap caused by dissection. A magnetic resonance aortogram clearly showed that the trans-esophageal echocardiogram was a false positive. In addition, multiplanar reconstructed images of the magnetic resonance aortogram through the tortuous descending thoracic aorta could reproduce images similar to that seen by transesophageal echocardiography. Because transesophageal echocardiography has become a popular imaging modality for the detection of aortic dissection, it is essential for echocardiographers to be aware of possible pitfalls which may create false positive findings

The blue toe syndrome is characterized by tissue ischemia secondary to cholesterol crystal or atherothrombotic embolization leading to occlusion of small vessels. Embolization occurs typically from an ulcerated atherosclerotic plaque located in the aorto-iliac-femoral arterial system. Clinical presentation can range from a cyanotic toe to a diffuse multiorgan systemic disease that can mimic other systemic illness. Mortality can be higher than 70% depending on the scope of the illness. Embolization can occur spontaneously or from a variety of insults such as invasive vascular procedures, anticoagulation, or thrombolytic therapy. Angiography, duplex ultrasonography, computerized tomographic scanning, and magnetic resonance imaging have been used to image the offending lesions, with angiography considered the 'gold standard' despite its inherent risks. Recently, transesophageal echocardiography has been shown to be a helpful tool in imaging the thoracic aorta and delineating in great detail the anatomy of the aortic atheroma. At present, surgery remains the most viable treatment option. However, we look to the future for large randomized trials to help predict embolization and thus the proper medical therapy

Surgical treatment of left ventricular aneurysms have recently focused on maintaining normal left ventricular geometry by using a circular patch repair to exclude the aneurysmal cavity (endoaneurysmorrhaphy). We describe two patients who underwent this procedure and were subsequently found by echocardiography and angiography to have a residual communication between the left ventricular cavity and the aneurysm which contained thrombus. This finding may have implications regarding the optimal hemodynamic result of the surgery and the risk of thromboembolism