Correction of Anomalous Subdiaphragmatic Inferior Vena Caval Drainage of the Right Pulmonary Veins (Scimitar Syndrome)

Correction of anomalous infradiaphragmatic inferior vena caval drainage of the right pulmonary veins can be repaired under conventional cardiopulmonary bypass by placing a circumferential tape below the diaphragm between the hepatic veins and the scimitar vein entrance. During repair, creation of an atrial septal defect in the distorted septal-left atrial junction of scimitar syndrome is facilitated by first incising the anteromedial aspect of the fossa ovalis to better delineate the optimal posterolateral margin. A case history illustrates the technique.     

Total Spinal Anesthesia: A Rare Complication of Intrathoracic Intercostal Nerve Block

Total spinal anesthesia following intrathoracic intercostal nerve blocks with bupivacaine performed for postoperative pain relief during thoracotomy is described. Possible mechanisms for this complication include: (1) inadvertent placement of the needle through an intervertebral foramen, (2) puncture of a long dural cuff, and (3) intraneural injection with central spread. Recognition of this potential complication is important, and facilities for proper support must be available.     

Legionnaires' disease after heart transplantation

The cases of 8 heart transplant recipients with legionnaires' disease are reviewed. The diagnosis in each patient was made by fluorescent antibody stains or direct culture of the sputum, transtracheal aspirate, or fine needle aspirate of the lung. All patients were successfully treated with erythromycin alone or in combination with rifampin. Radiographic and clinical variations of legionnaires' disease as seen in the immunocompromised host are presented.     

Systemic Effects of Multidose Hypothermic Potassium Cardioplegia

The purpose of this study was to investigate the changes in serum and urine potassium before, during, and after the administration of potassium cardioplegia using a solution containing 28 mEq/L of potassium chloride in 20 consecutive patients with acquired heart disease. The data obtained suggest that the concentration of potassium administered does not result in inordinately elevated serum potassium levels (peak, 4.6 ± 0.18 mEq/L at 2 hours of multidose hypothermic potassium cardioplegia) during or after infusion. Additionally, the urinary excretion of potassium increased during infusion and eventually exceeded the amount of potassium infused. While hypothermic potassium cardioplegia appears to be a safe and efficient method of myocardial protection, continued surveillance of postoperative potassium levels remains necessary to detect obligatory urinary potassium excretion following cardiopulmonary bypass and operation.     

Neonatal pneumopericardium: a surgical emergency

Transhiatal esophagectomy without thoracotomy has been utilized in 200 patients: 57 with benign disease and 143 with carcinomas at various levels of the esophagus (35 pharyngeal or cervicothoracic, 7 upper third, 47 middle third, and 54 distal third). Stomach has been used to replace the esophagus in 93% of patients undergoing single-stage esophagectomy and reconstruction, and colon has been used in 7%. Among patients with intrathoracic esophageal carcinomas, intraoperative blood loss averaged 1,000 ml, and the hospital mortality was 6%. No patient in the entire series has required a thoracotomy for control of bleeding, either during the esophagectomy or postoperatively. This report reviews the technical maneuvers that my collegues and I have found useful in performing transhiatal esophagectomy without thoracotomy.     

Platelet Loss during Experimental Cardiopulmonary Bypass and Its Prevention with Prostacyclin

Prostacyclin (PGI₂), a newly discovered short-acting prostaglandin that inhibits platelet aggregation, was evaluated as an agent for prevention of cardiopulmonary bypass–induced thrombocytopenia. Ten adult, splenectomized greyhounds were divided into three treatment groups prior to beginning 120 minutes of partial cardiopulmonary bypass. Group 1 animals received 300 units of heparin per kilogram of body weight, Group 2 animals received 300 units of heparin per kilogram plus PGI₂, 1.5 μg per minute, and Group 3 animals received 300 units of heparin per kilogram plus PGI₂ 3.0 μg per minute. Bypass and PGI₂ infusion were started simultaneously.Mean platelet counts of each group at 5 minutes were approximately 40% of prebypass levels. Additional platelet loss was seen in Groups 1 and 2 at 30, 60, and 120 minutes. However in Group 3, platelet counts at 30 and 60 minutes were essentially unchanged from prebypass levels. At 30, 60, and 120 minutes of cardiopulmonary bypass, the differences between Groups 1 and 3, and 2 and 3 are highly significant (p < 0.01).We conclude that PGI₂ is an effective agent for preserving platelet levels during experimental cardiopulmonary bypass. Furthermore, it is possible that platelet loss during cardiopulmonary bypass may be caused, in part, by an imbalance between PGI₂ and thromboxane A₂, which results in excessive platelet adhesion and aggregation.     

Comparison of Dopamine and Dobutamine Following Coronary Artery Bypass Grafting

A prospective, randomized comparison of the hemodynamic effects of dopamine and dobutamine was performed in 20 patients following coronary artery bypass grafting. Approximately 6 hours postoperatively, when patients were hemodynamically stable, either dopamine or dobutamine was administered at 2.5, 5.0, and 7.5 μg per kilogram of body weight per minute. At 5.0 μg/kg, both drugs increased cardiac index without changing heart rate, mean arterial pressure, pulmonary capillary wedge pressure, or peripheral vascular resistance. At 7.5 μg/kg, dobutamine caused a further increase in cardiac index without changing the other variables. In contrast, increasing dopamine from 5.0 to 7.5 μg/kg/min caused significant increases in mean arterial pressure, pulmonary capillary wedge pressure, and pulmonary vascular resistance but no further increase in cardiac index. We conclude that dobutamine is preferable to dopamine in patients following coronary artery bypass grafting, since it produces consistent, dose-related increases in cardiac index without increases in heart rate, mean arterial pressure, pulmonary capillary wedge pressure, or pulmonary vascular resistance.     

Surgical Manifestations and Results of Treatment of Pulmonary Coccidioidomycosis

Fifty consecutive patients with pulmonary coccidioidomycosis undergoing operation in an eight-year period were analyzed with regard to clinical and roentgenographic indications, surgical procedure, complications, and recurrence. Surgical indications could be divided into operation necessary primarily for diagnosis (22 out of 50, 44%), and operation because of suspected residual complications of coccidioidomycosis requiring therapy (28 out of 50, 56%). Of 16 patients with solitary nodules, 2 had lobectomy and 14 had wedge resection with no recurrence. Of 24 patients with coccidioidomycosis cavities, 14 underwent lobectomy and 10 had lesser resections, with three recurrences.Results indicate that (1) resection for primary pulmonary coccidioidomycosis for both diagnosis and therapy is associated with low perioperative risk, (2) routine administration of amphotericin is not indicated, (3) skin tests, serological study, bronchoscopy, and mediastinoscopy may not be diagnostic, and (4) lobectomy is not necessarily indicated since lesser resections are associated with equally low recurrence and complications rates.     

Retrieval of an embolized polyethylene catheter: a new use for the Schultze endomyocardial bioptome

The Schultze endomycardial bioptome was used to retrieve an embolized portion of plastic catheter from the right ventricle of a 5-month-old child. The retrieval was accomplished using fluoroscopy and took no more than two minutes after placement of the bioptome in the right internal jugular vein.     

Operative Treatment of Congenital Aortic Stenosis

The operative treatment of 131 patients with congenital aortic stenosis is reviewed. Of the 131 patients, 77% had left ventricular outflow tract (LVOT) obstruction at a single level and 23%, major obstruction at more than one level. There were 3 operative deaths (2.3%) and 10 late deaths (7.8%).Twenty of the 128 discharged patients have undergone a second procedure and 6 a third procedure for recurrent or residual LVOT obstruction. The 26 reoperations included 7 aortic valve replacements, 4 left ventricular apical-abdominal aortic (LV-AA) valved conduits, and 15 extensive aortic valvotomies with or without supravalvular aortoplasty. Five of the 20 patients undergoing reoperation died; 4 of these deaths occurred in patients who had valve replacement at reoperation. The 4 who received LV-AA conduits have sustained excellent hemodynamic and clinical results with no complications.Highly satisfactory clinical results can be obtained with minimal operative risk, regardless of the level of LVOT obstruction. Reoperation for recurrent or residual LVOT obstruction, however, is comparatively more hazardous, and alternative surgical approaches (LV-AA conduits) should be considered.     

Microvascular changes in Dupuytren's contracture

Previous studies of certain fibrotic lesions (hypertrophic scar, keloid, pseudotendon) have revealed pervasive microvascular occlusion. Lowered oxygen tension is considered to be a stimulus to excessive collagen production and, hence, the scar. Because its characteristics are similar to those of other lesions, Dupuytren's contracture appeared to be a good model in which to confirm the presence of occluded microvessels. Six cases were examined by light, electron, and polarizing microscopy. Most of the microvessels from the precontracture band area throughout the periphery of the body of the nodules were occluded by a bulging of the endothelial cells into the lumen. The microvessels were surrounded by extensive layers of basal laminae. The nodules were essentially avascular. The presence of another fibrotic lesion in which pervasive microvascular occlusion occurs is suggestive of an underlying biologic principle concerning the generation of all fibrotic lesions.     

Sternal staple: simple and rapid device for closure of median sternotomy.

A new device for rapid and secure closure of median sternotomy has been developed, clinically proved, and found to be an excellent additional tool for the armamentarium of the thoracic surgeon.     

Acute traumatic rupture of the aorta. A re-emphasis of repair without a vascular prosthesis

The incidence of acute aortic rupture has paralleled the increasing number of high-speed vehicles on our highways. Repair of acute aortic rupture without a vascular prosthesis has been mentioned frequently but seldom applied. Three consecutive patients with acute rupture repaired without a vascular prosthesis are discussed. The advantages of this technique are reviewed, and technical factors of the operation are described.     

Single Catheter Technique for Cardioplegia and Venting during Coronary Artery Bypass Grafting

Two areas of current controversy concerning coronary artery bypass operations involve the use of cardioplegia and the need for left ventricular venting. We wish to describe a very simple, safe, and effective method of accomplishing both cardioplegic arrest and venting using a single 14-gauge catheter inserted into the aortic root.     

Effects of glucose therapy on experimental Escherichia coli septicemia.

Therapeutic and prophylactic employment of glucose infusion during E. coli septicemia apparently induces a reversal of the effect, manifested by the presence of the organism and its by-products. Dogs, receiving a continual infusion of E. coli at 1 × 10⁷/ ml with elevated blood glucose levels, showed a 1000-fold decrease in circulating bacteria within 2 hr when compared with control animals. Dogs prophylactically treated cleared circulating E. coli in 30 to 60 min, sooner than control animals.Glucose infusion employed therapeutically and prophylactically has a curative effect in Gram-negative septicemias and bacteremias.     

Angioplastic repair of a ruptured pulmonary artery aneurysm.

A 28-year-old woman had a ruptured solitary pulmonary arterial aneurysm which was successfully treated by pericardial patch graft. The etiology of the aneurysm could not be determined although the patient had had several episodes of blunt chest trauma in the past. Unusual aspects of this case include: location of the aneurysm in the intermediate portion of the left pulmonary artery within the major intralobar fissure, intrapleural rupture, preoperative diagnosis by pulmonary angiography, and an incidentally discovered histopathological abnormality of the aneurysm itself for which no satisfactory explanation has been found.