The Sutureless Electrode: Comparison with Transvenous and Sutured Epicardial Electrode Placement for Permanent Pacing

Consecutive series of 50 transvenous and 50 sutureless pacemaker insertions were reviewed and compared with a nonsimultaneous series of 50 patients who received sutured epicardial pacemakers. It is concluded that: (1) the sutureless electrode has a lower initial stimulation threshold than the transvenous type; (2) complications from sutureless electrodes are greater than with transvenous electrodes and similar to the incidence with sutured epicardial pacemakers; (3) initial pacing is more satisfactory with the sutureless electrode compared with the transvenous model; and (4) late electrode failure due to threshold rise is greater with the sutureless electrode than with the transvenous or sutured epicardial type.     

Bacteremia,Endocarditis, and the Hancock Valve

Among 373 patients with porcine xenografts, there were 27 instances of exposure of the xenograft to bloodstream or endocardial infection in 22 patients. Nine patients underwent 10 separate insertions of xenografts for active infective endocarditis. There were no early infections or valve failures. Three patients returned with a late prosthetic valve endocarditis (PVE) due to a new infection. There were 6 instances of bacteremia early after xenograft valve insertion with no early infection, no valve dysfunction, and 1 instance of late PVE. Eleven patients had PVE on a porcine xenograft. Blood cultures in the 10 patients treated with antibiotics promptly became negative. There were 3 valve-related deaths: 2 from valve incompetence and 1 from mitral and aortic xenograft stenosis. Our experience suggests that the Hancock porcine xenograft is: (1) as resistant to infection as are rigid prostheses in active infective endocarditis; (2) resistant to early postoperative bacteremias; and (3) easier to sterilize than rigid prostheses and more durable than other tissue valves in the face of PVE.     

Auxiliary Heart Transplantation

At the present time, the major obstacles in the successful clinical application of heart transplantation are the immunological attack on the allograft, the treatment of complications resulting from immunosuppression, and the supply of transplantable hearts. Recently, auxiliary heart transplantation has been proved to be a successful technique for treatment of end-stage myocardial failure in humans. Here we review the experimental work in auxiliary heart transplantation leading to the preent technique used in humans.     

Failure of standard cardioplegic techniques to protect the conducting system

To determine the site of persistent electrical activity during cardioplegic arrest, microelectrodes that were also capable of recording temperature were placed along the conducting system in dogs undergoing one hour of cardioplegic arrest. Electrical activity was highest in the atrioventricular (AV) junction area (AV node and proximal bundle of His), and the temperature in this area could not be lowered to the level of the temperature in the left ventricular apex by routine cardioplegic technique. Neither changing K+ concentration (16 to 20 mEq/L) nor adding procaine hydrochloride abolished the activity of the conducting system during cardioplegia, and only 2 of 15 dogs were in sinus rhythm 30 minutes after reperfusion. When the conducting system temperatures were lowered to less than 15 degrees C by right AV lavage with iced saline solution, electrical activity was abolished during arrest and all 4 of 4 animals were in sinus rhythm 30 minutes after reperfusion. This study localizes the site of persistent conducting system activity during cardioplegic arrest, confirms it can be abolished with local cooling, and establishes the relationship between conducting system activity during cardioplegia and the incidence of conduction block and junctional rhythm following reperfusion.     

Rifampin in the Management of Early Prosthetic Staphylococcus epidermidis Endocarditis

Staphylococcus epidermidis endocarditis occurred four days following aortic valve replacement with a Björk-Shiley prosthesis. Antimicrobial therapy, shown to be effective by in vitro and in vivo studies, failed to eradicate the infection. When rifampin was added to the existing antibiotic regimen, peak serum bactericidal activity increased, the patient defervesced, and blood cultures became negative.     

Relation of calcification to torn leaflets of spontaneously degenerated porcine bioprosthetic valves

The gross appearance of 54 spontaneously degenerated porcine bioprosthetic valves was evaluated to determine the relation of calcium deposition to cusp disruption. Tears or perforations were shown in 89% (48) of the degenerated valves. The most common site of tears or perforations was near the commissural attachment (60% of all tears). Grossly visible deposits of calcium salts that ruptured to the surface of the cusps or caused changes in the topography were observed in 70% (38) of the 54 valves. Calcification was adjacent to tears or perforations in 56% (27) of the 48 valves with torn cusps. Among the valves that showed calcification, the deposits of calcium salts were adjacent to tears or perforations in 71% (27 of 38). The location of deposits of calcium did not relate to the age or sex of the patient or to the position of the valve, but valves with calcium were inserted longer than valves with no calcium (87 +/- 4 versus 58 +/- 7 months; p less than 0.001). The outflow surfaces showed more calcification than the inflow surfaces, irrespective of whether the valves were in the aortic or mitral position. Among the 38 valves with calcification, 92% (35) showed calcification at the commissural attachments, 53% (20) showed calcification in the body of 1 or more cusps, 11% (4) near the base, and 8% (3) near the free edge. In conclusion, most patients with spontaneous porcine valve degeneration showed calcification. The calcification was associated with tears or perforations of the cusps in 50% of all degenerated valves, in 56% of valves with torn cusps, and in 71% of valves that showed gross calcification.     

Spontaneous Degeneration of Porcine Bioprosthetic Valves

From October, 1971, to October, 1979, 490 patients with 560 porcine bioprosthetic valves were discharged from the hospital. During these 8 years, 23 valves were removed because of failure due to spontaneous degeneration. Bioprosthetic valve survival without degeneration was at 4 years, 98.9% ± 0.6 (standard error); at 5 years, 96.4% ± 1.3; at 6 years, 90.8% ± 2.4; and at 7 years, 84.2% ± 3.7. There was no difference in degeneration observed with regard to sex, valve position, or whether the valves were rinsed with antibiotics prior to implantation. There was an increase in degeneration in patients 35 years old and younger compared with those more than 35 years old (p = 0.0001). Valve failure was gradual, and valve changes were noted by echocardiogram and phonocardiogram prior to actual failure. Specific factors leading to degeneration require further investigation.     

Massive Hemoptysis: Control by Transcatheter Bronchial Artery Embolization

Massive hemoptysis (600 ml in 48 hours) has an ominous prognosis with a mortality of 50 to 100% in medically treated patients and up to 35% in patients undergoing operation. Surgical resection has been the procedure of choice in patients with massive hemoptysis. Those with a contraindication to operation present a particularly frustrating problem. We have treated 7 such patients with massive hemoptysis by transcatheter bronchial artery embolization. In all 7, the bleeding was arrested. Two patients died of recurrent hemoptysis, 1 ten days and the other 2 months following embolization, and 5 are well 1 month to one year later. Transcatheter bronchial artery embolization is a valuable therapeutic modality in patients with massive hemoptysis. However, the procedure is palliative, and, therefore, elective resection must be considered as definitive treatment in those patients who have no contraindication to operation.     

Effects of pulsatile perfusion pressure and storage on hearts preserved for 24 hours under hypothermia, for transplantation.

Canine hearts preserved for 24 hours under hypothermic pulsatile perfusion at a systolic pressure of 25 mm Hg had better perfusion and transplantation survival results than hearts perfused at 50 or 80 mm Hg. Also, hearts perfused at a systolic pressure of 25 mm Hg did better than simple hypothermically stored hearts or fresh allografts. These findings indicate that hearts are adequately perfused for 24 hours under hypothermia for transplantation at a systolic pressure of 25 mm Hg.     

Prospective randomized evaluation of intrathoracic intercostal nerve block with bupivacaine on postoperative ventilatory function.

This prospective and randomized study demonstrates the beneficial effect of intrathoracic intercostal block with bupivacaine on the recovery of pulmonary function after thoracotomy. A significantly (p less than 0.05) better forced expiratory volume was seen in the treated group in the early post-operative period. Similar findings were observed in forced vital capacity. Also, the requirements for analgesics were decreased in the treated group. We believe that intrathoracic intercostal block with bupivacaine when properly utilized can be a good adjuvant in the improvement of pulmonary function after thoracotomy.     

Pulmonary edema: reversal by ultrafiltration

Ultrafiltration, the process by which plasma water is removed from the blood was utilized to determine its effect on lowering lung water in pulmonary edema produced by fluid overload, steam inhalation, and endotoxin. Lung water was measured by the thermal-dye indicator dilution technique which correlated well with lung water measured gravimetrically over a wide range (r = 0.95). Edema was produced by fluid overload in five mongrel dogs (Group I), by steam inhalation (Group II), and by endotoxin (Group III). Extravascular lung water (EVLW) rose significantly (P = less than 0.05) from control levels with the production of the edematous states (Group I: 8.0 ml/kg (mean) +/- 1.9 (SD) to 13.1 +/- 1.9); (Group II: 8.1 +/- 1.0 to 10.7 +/- 0.7); (Group III: 7.4 +/- 0.9 to 10.3 +/- 1.2). EVLW then fell significantly (P = less than 0.05) after ultrafiltration in all three groups (Group I: 8.9 +/- 2.4; Group II: 7.8 +/- 1.9; Group III: 7.7 +/- 1.4). Ultrafiltration was effective in reversing pulmonary edema and may have clinical application when excess lung water interferes with cardiac or pulmonary function.     

Mitral valve replacement with viable aortic homograft valves

Forty consecutive patients underwent mitral valve replacement with viable aortic valve homografts. Viability was assessed by autoradiography in a sample of the aortic wall of the graft at the time of insertion. Sixty to 75% of the fibroblasts were found to be metabolically active.All patients were in New York Heart Association Functional Class III or IV prior to operation. Pulmonary hypertension was present in 37. One patient died in the hospital, and 1 late death occurred 9 months postoperatively. Anticoagulants were discontinued 6 weeks after operation without thromboembolic complications. Thirty-six of the patients showed marked clinical improvement, and only 3 patients were found to have a mild degree of mitral regurgitation by angiography.This experience has encouraged us to continue with this method of mitral valve replacement.     

Comparative study of different pancreas transplantation modalities: Islet cell vs organ pancreas transplantation in pancreatectomized dogs

This report confirms the satisfactory results obtained with splenic autotransplantation of islet cells or organ pancreas transplantation. When the allotransplantation technique was utilized, the islet cells rejected significantly faster than the organ pancreas grafts. Rejection in the allotransplant model was correlated with high levels of glucose and amylase at the onset of this phenomenon in the organ graft group and only elevation of glucose in the islet cell group. A progressive increase of these levels was continued after the first rejection was established and this persisted until death. Our data in the dog appear to indicate that islet cell allotransplantation is not justified clinically until better methods to control rejection are introduced. However, islet cell autotransplantation appears to be a good technical advancement in cases with pancreatitis undergoing total or near total pancreatectomy. Organ pancreas transplantation appears to be a good technique for allotransplantation in virtue of our results observed in the dog that has been moderately immunosuppressed.     

Periosteal (juxtacortical) chondrosarcoma: Report of a case occurring in the hand

A rare case of periosteal (juxtacortical) chondrosarcoma of the hand is described. Inadequate excision was followed by recurrence which necessitated a transmetacarpal amputation to eradicate the malignant disease.     

Operative treatment of benign gastric ulcers

Between the years 1953 and 1963, 1,583 patients at the Henry Ford Hospital were recorded as having gastric ulcer. Of this number 150 (9.4 per cent) underwent operative treatment. Failure to respond favorably after medical treatment and suspicion of malignancy prompted surgical intervention most often.Two operative approaches were commonly employed. Gastric resection plus vagotomy with Billroth I reconstruction was utilized in fifty-three patients. Gastric resection with vagotomy and Billroth II reconstruction was the procedure of choice in twenty-nine patients. Thus, eighty-two patients had gastric resection with vagotomy. There were four recurrences in this group (5 per cent). The second largest group of patients were those upon whom gastric resection was performed without vagotomy. The Billroth I reconstruction was performed thirty-one times and the Billroth II procedure was employed twenty-one times. There were nine recurrences in fifty-two patients, a recurrence rate of nearly 17 per cent. Clearly, in this study, gastric resection with vagotomy gave better results (5 per cent recurrence) than did gastric resection alone (17 per cent recurrence). The over-all recurrence rata for 150 patients was approximately 11 per cent.In eight patients the clinical diagnosis was benign ulcer when, in fact, malignancy was present. In two patients, the tumor was lymphoma. Only one of ten patients died of tumor. Excellent follow-up studies were possible in every patient with a malignant lesion. Adequate gastric resection is effective for these small, unsuspected ulcerocarcinomas.There were four postoperative deaths, a mortality rate of 2.7 per cent. Two patients died of myocardial infarction and two died of pulmonary emboli.