Hemodynamic observations during and after pulmonary artery banding

Analysis of cardiac catheterization in 25 patients with nonrestrictive ventricular septal defect (Prv/Plv > 0.6) shows that the pulmonary vascular resistance and systemic vascular resistance function as resistances in parallel. Furthermore, studies in the presence of right ventricular outflow obstruction, by either pulmonary artery band (9 patients) or pulmonary stenosis and ventricular septal defect with left-to-right shunting (12 patients), show that the right ventricular outflow obstruction (band) functions as a resistance in series with the pulmonary vascular resistance. The sum of pulmonary vascular resistance plus band resistance is in parallel with systemic resistance. This concept allows better explanation of the great pressure variability across bands observed at operation. It is impossible to completely evaluate a pulmonary artery band with pressures alone. Flow measurements are necessary for better understanding of pulmonary artery bands. The variability of clinical response after banding may be explained by the variations in pulmonary vascular resistance and systemic vascular resistance during and after pulmonary artery banding.     

The role of thymectomy in red cell aplasia.

Red cell aplasia is an unusual cause of anemia. Fifty percent of all patients with red cell aplasia will have a thymoma. Twenty-five to 30% of those who undergo thymectomy will be cured. Data are presented that suggest that any patient with red cell aplasia should have thymectomy through a median sternotomy. One of 3 such patients who underwent the operation has had complete remission for two years.     

Absent left innominate vein: sign of persistent left superior vena cava.

Pharmacological agents administered prior to the institution of myocardial anoxia or ischemia may protect the myocardium by preventing ATP depletion, structural damage to cell membranes and organelles, and postanoxic disturbances in coronary microcirculation. Propranolol, dipyridamole, nitroglycerin, and mannitol all have the potential to protect the myocardium in one or more of these ways and thus have promise for clinical use.     

Acute Traumatic Hemothorax

Over the past 5 years, 107 patients have been evaluated for acute traumatic hemothorax at the University of Kentucky Medical Center. Immediate tube thoracostomy was performed on 90 patients for evacuation of blood and air. Only 2 patients died. Thoracotomy was performed as part of the initial therapy in 9 patients. Thoracotomy for continued hemorrhage from a pulmonary parenchymal injury was required in 3 patients from the entire group.Thoracentesis or observation was the initial therapy for limited hemothorax in 8 stable patients. Three of these patients subsequently required tube thoracostomy 2 to 23 days following injury due to expanding effusions, and 1 patient required multiple thoracotomies for sepsis, fibrothorax, and empyema.These observations indicate that early evacuation of blood by means of a tube thoracostomy is essential to minimize morbidity in acute traumatic hemothorax. If continuing hemorrhage after tube thoracostomy occurs, there is a higher association of injury to additional vital structures.     

Management of Ascending Aortic Aneurysm Complicating Coarctation of the Aorta

Four patients with coarctation of the aorta complicated by an aneurysm of the ascending aorta are described. One patient, treated only medically, died suddenly. For the 3 patients who underwent operation, management was similar. Pharmacological control of blood pressure and repair of the aortic coarctation to achieve anatomical reduction in afterload (stage I) were followed after an interval of one to five weeks by surgical repair of the ascending aortic aneurysm (stage II).Initial repair of the coarctation relieves proximal hypertension, thereby decreasing the chance of progressive dissection or rupture of the aneurysm. It also permits safe arterial cannulation for perfusion during correction of the aneurysm in the second stage. In patients not requiring valve replacement in stage II, continued long-term follow-up for progression of aortic valvular disease appears to be necessary.     

A New Approach to Pseudoaneurysm of the Ascending Aorta

A pseudoaneurysm of the ascending aorta was repaired successfully with Fogarty balloon occlusion and bypass employing cardiotomy suckers. This previously unreported application of a basic vascular technique can simplify management in selected patients.     

Repair of Mycotic Aneurysms of the Aorta Involving the Aortic Valve

This report summarizes our successful management of 6 patients who underwent repair of mycotic aneurysms of the ascending aorta within a four-year period. Repairs have been successful despite involvement of as much as two-thirds of the circumference of the aortic valve annulus, involvement of the origin of the right coronary artery, and development of heart block. Three patients required surgical intervention because of hemodynamic decompensation before they had completed antibiotic therapy for endocarditis.In 3 patients, the aneurysm was buttressed with the valve skirt so that aneurysm repair and valve replacement were accomplished in continuity. In 2 patients, the aneurysm was repaired separately and the valve seated on the repair. In 1 patient, a large defect between the left and right coronary arteries was repaired with a woven Dacron patch secured to the valve skirt. The valve was seated to the left ventricle and the graft to the aorta. There were no operative or postoperative deaths. Our data suggest that mycotic aneurysms of the aortic annulus can be successfully repaired despite extensive damage.     

Palliation for esophageal carcinoma

Fifty-three patients with carcinoma of the esophagus treated since 1972 are reviewed. Eighteen unresectable patients with distant metastases or pulmonary insufficiency were treated with irradiation or with esophageal or gastrostomy tubes plus irradiation. There were 5 early deaths, and only 3 patients survived more than three months. Six patients underwent bypass. Three died in the hospital, and 1 lived three months. None compled a course of irradiation or gained weight. The remaining 29 patients, who did not differ clinically from the bypass group, underwent resection for palliation or cure. There were 5 hospital deaths. Twenty patients lived more than three months and 7 of these more than one year. Two of them apparently were cured. These data indicate that the only effective means of increasing the duration of survival for esophageal carcinoma is resection with immediate reconstruction.     

Structure-related thrombosis involving a porcine xenograft valve.

A patient developed acute congestive heart failure following chordal rupture and underwent mitral valve replacement with a porcine xenograft. He recovered adequate hemodynamic function but died one month later with widespread bronchopneumonia. Postmortem examination revealed a prominent muscular shelf in the right coronary leaflet of the xenograft, and focal thrombosis involving the adjacent sewing ring and left atrial wall. The location of the thrombus suggests that it formed as a result of local stasis behind the large muscular shelf. Limiting the size of this muscular shelf by valve selection and construction may reduce the thrombogenicity of this prosthesis.     

Successful Liver Transplantation From a Donor With a Continuous-Flow Left Ventricular Assist Device for 9 Months

Organ donor criteria continue to be extended in an attempt to meet growing demands. Patients with continuous-flow left ventricular assist devices are one group of potential donors being considered. One concern with this group is the effect of continuous flow for a prolonged duration, as opposed to normal pulsatile flow, on end-organ function. We report the 1st case of a liver transplantation from a donor who had a continuous-flow left ventricular assist device for 9 months. The recipient was a 69-year-old woman with a history of cryptogenic cirrhosis and hepatocellular carcinoma. The transplantation was complicated by moderate acute cellular rejection as well as biliary obstruction requiring sphincterotomy and stent placement. After management of those complications, the patient's liver function tests returned to normal values and remained stable at her 6-month post-transplantation follow-up. This case shows that organ transplantation from a donor with a continuous-flow left ventricular assist device for a prolonged period can be performed successfully.     

Pacemaker wire extension for permanent and temporary pacing

A pacemaker wire extension was designed and used for temporary pacing in the postoperative period following open-heart operations. When permanent pacing became indicated, the exteriorized extension was removed and the pacemaker was connected to the permanent electrode and placed subcutaneously. This extension wire eliminated repeat thoracotomy following tricuspid valve replacement and enabled us to implant one reliable set of wires to the myocardium. The extension is easily removed using firm traction (Cordis) or local anesthesia (Medtronic).     

Device for the rapid insertion of a permanent endocardial pacing electrode through the subclavian vein: preliminary report.

A technique is described for rapid introduction of a permanent transvenous pacemaker electrode through a subclavian puncture utilizing a specially constructed introducer. The technique is safe and atraumatic and can locate the pacing electrode within the right atrium in 2 to 4 minutes.     

Operative repair for tricuspid atresia.

Twelve patients with tricuspid atresia underwent physiological operative repair. The criteria for their selection for operation included normal pulmonary vascular resistance and normal left atrial and left ventricular end-diastolic pressures. Four patients died (30% mortality). The 8 surviving patients developed pleural effusion, ascites, and hepatomegaly, which markedly improved in the subsequent weeks. Five of the 8 survivors underwent cardiac catheterization. The arterial oxygen saturation in these patients averaged 82% preoperatively, 89% immediately postoperatively, and 94% or better six months later. All had improved subjectively and developed increased exercise tolerance.     

Middle Lobe Syndrome: Diagnosis and Management

Ninety-eight patients with middle lobe syndrome were reviewed. There were 31 male and 67 female patients ranging in age from 4 to 80 years. The most common presenting symptoms were cough, dyspnea, fever, hemoptysis, and chest pain. Diagnostic studies included chest roentgenogram, bronchoscopy, and bronchography. Sixty-five patients had full recovery following intensive medical therapy. Thirty-one patients underwent surgical resection for persistent disease. There were five postoperative complications and 1 death in this series.     

Acute Empyema in Children Treated by Open Thoracotomy and Decortication

Acute nontuberculous empyema treated conventionally by thoracentesis, thoracostomy drainage, and antibiotics has an unacceptably high rate of morbidity and mortality. Early open thoracotomy to eliminate the empyema with decortication of the fibrinous peel and reexpansion of the lung has proven safe and effective for 25 years.The goals of treatment of acute nontuberculous empyema are: (1) to save life, (2) to eliminate the empyema, (3) to reexpand the trapped lung, (4) to restore mobility of the chest wall and diaphragm, (5) to return respiratory function to normal, (6) to eliminate complications or chronicity, and (7) to reduce the duration of hospital stay.Our studies confirm the normal values to be expected in patients who have had complete recovery from the acute empyema, and we lay to rest any concern that decortication might, in time, limit pulmonary function.We present the cases of 21 children who had acute and mature empyemas that were treated by open thoracotomy and decortication, with an average follow-up of 18 years, among whom there were no deaths or complications.     

Noncoronary collateral myocardial blood flow.

This study shows that noncoronary collateral flow occurs in normal hearts after chronic coronary occlusion and with left ventricular hypertrophy in variable amounts (0.2 to 16 ml/100 gm/min). Luminal--left ventricular flow is greatest when the heart is arrested by aortic cross-clamping, falls significantly when perfusion pressure is lowered to 50 mm Hg, and increases slightly when blood viscosity is reduced (hemodilution). Our findings indicate that the heart which is arrested by aortic cross-clamping may not be anoxic.     

A permanent experimental model for reversible myocardial anoxia

A new permanent preparation for studying myocardial response to reversible ischemia was defined and characterized in 46 dogs. The left mammary artery was anastomosed to the second diagonal branch of the left anterior descending coronary artery. The artery distal to the anastomosis served as the sole vascular supply for a myocardial pedicle created by a simultaneous incision and suture technique. The venous drainage was left intact, draining blood to the great cardiac vein and coronary sinus.The pedicles so constructed were an anatomically defined myocardial segment with an independent yet controllable vascular supply that maintained viable, functioning tissue. Functional continuity with surrounding myocardium was preserved. There was no damage to adjacent tissue. Overall ventricular function was maintained, and permanent preparations were readily available for study. Occlusion of the mammary artery for a 15-minute period produced structural and functional changes that were completely reversible with 30 minutes of revascularization. Sixty minutes of occlusion produced severe morphological and functional damage that was only slightly reversible. Additional applications of the model are discussed.     

Permanent pacing through a persistent left superior vena cava: an approach and report of dual-chambered lead placement

The patient with a persistent left superior vena cava who requires permanent pacing presents difficulties if no right superior vena cava is present or if it is encountered unexpectedly at pacemaker implantation. A case is presented that illustrates potential problems and suggests a general approach to this situation. Successful transvenous universal pacemaker insertion through a persistent left superior vena cava is reported.