Analysis of surgical versus medical therapy in active complicated native valve infective endocarditis

From 1972 to 1980, 23 patients (Group A) with native valve infective endocarditis underwent surgical intervention, often for multiple indications, during the active stage of the infective process because of progressive class III and IV (New York Heart Association) heart failure (12 patients), persistent severe hypotension (3 patients), uncontrolled infection for over 21 days (11 patients), aortic root abscess (2 patients), and pericarditis (1 patient). Eighty-five patients (Group B) with active native valve endocarditis, matched for severity of illness, were treated medically. Two patients (9%) in Group A and 43 patients (51%) in Group B died during the hospital admission (p < 0.001). Any difference in long-term cumulative survival rate between the 2 groups was largely due to the beneficial impact of surgical management on the hospital mortality. Of 23 patients in Group A, 11 (48%) had an entirely uncomplicated postoperative course. Long-term mortality rates in those with aortic valve endocarditis treated medically (79%) were significantly higher than in those with mitral valve involvement (47%) (p < 0.05). Patients with aortic valve involvement treated surgically had a better hospital (p < 0.005) and long-term (p < 0.005) survival rate than those treated medically. Two groups at risk for postoperative complications were identified; 3 of 11 patients (27%) with uncontrolled infection had an early postoperative recurrence, and 4 of 7 patients (57%) with an aortic root abscess had postoperative prosthetic paravalvular regurgitation.

Surgery therefore effects a substantial reduction in hospital mortality in patients with complicated active infective endocarditis (9% versus 51%), but patients with preoperative prolonged periods of uncontrolled infection or with aortic root abscess are liable to postoperative complications.     

Purpura fulminans

Purpura fulminans presents as a catastrophic illness with gangrene of the distal extremities and necrosis of skin. The clinical picture consists of septicemia, shock, and disseminated intravascular coagulation. The Shwartzman and Arthus reactions are thought to be responsible for the pathogenesis of purpura fulminans. The exact mechanisms of these reactions are not completely understood. Immediate resuscitation is the treatment for shock and sepsis. Heparin is recommended to reverse the disseminated intravascular coagulation component of this disease. Surviving patients require treatment of skin necrosis and digital and extremity gangrene. The former are managed in a fashion similar to the management of burns. Amputation should be delayed until maximal collateral circulation has developed. A series of 10 patients is presented and 58 cases from the literature are analyzed.     

Porcine Valve Bioprosthesis: Early Thrombosis with Systemic Emboli

We report the case of a patient who had early postoperative thrombosis, with systemic emboli, of an aortic Hancock porcine valve bioprosthesis. Anticoagulants were not used postoperatively because the patient had a history of epistaxis. Progressive symptoms and a 57 mm Hg transvalvular gradient prompted reoperation at six months. Thrombosis of the valve may have been related to postoperative low cardiac output, prolonged dysrhythmias, or lack of anticoagulants.     

Whole body plethysmography as a noninvasive assay of toxic lung injury in mice: Studies with the pulmonary alkylating agent and cytotoxin, 4-ipomeanol

The effect of 4-ipomeanol on the lungs of experimental animals often is measured by destructive assays, such as death, histology, or pulmonary alkylation. Breathing rate is a noninvasive assay routinely used to quantify the effects of radiation on the lungs of mice, which may be useful in assessing injury from other lung toxins. The effects of graded single doses of 4-ipomeanol on the breathing rate of mice were studied up to 3 weeks after treatment. Changes in breathing rate were observed up to 4 days after 4-ipomeanol treatment with nonlethal doses of the compound giving a clear, dose-dependent increase in breathing rate at 8 hr and 4 days after treatment. Time course and dose-response studies showed good agreement between changes in breathing rate and pulmonary alkylation after 4-ipomeanol treatment. Pretreatment of the mice with diethylmaleate (DEM) increased the pulmonary alkylation and toxicity of 4-ipomeanol. However, breathing rate was severely depressed by all doses of DEM that were examined. This decrease was not dose dependent within the range of doses studied. These studies indicate that breathing rate can be used to quantify the effects of nonlethal doses of 4-ipomeanol on the lungs of mice and does not require killing the animal. The technique may be similarly applicable to studies of other pulmonary toxins, but careful attention must be given to time and dose relationships and the possible effects of other drugs or pretreatments.     

Experience with central high flow arteriovenous fistulas in patients requiring chronic parenteral chemotherapy or hemodialysis

Fifty central high flow arteriovenous fistulas were constructed using bovine arterial heterograft during the past four years to provide vascular access in forty-four patients requiring cyclic infusion chemotherapy or chronic hemodialysis. Overall long-term patency of thirty-six axillary-axillary and fourteen axillary-internal jugular fistulas was approximately 80 per cent, and of those fistulas that failed, 87 per cent were successfully revised. All failures occurred within the first year after construction and were confined to the group of patients receiving cyclic infusion chemotherapy. Most of the failures could be directly related to constant rather than intermittent use of the fistulas. Complications other than graft occlusion occurred in three patients and prompted surgical intervention—in one patient for brachial artery thrombosis, in one for unilateral facial edema after axillary-internal jugular fistula, and in one for aneurysmal degeneration of the midsegment of one axillary-axillary graft. There was no operative mortality, and there were no septic, hemorrhagic, or significant wound healing complications in this high risk group of patients. Hemodynamic evaluations of both acute and chronic fistulas showed an approximate 20 per cent increase in cardiac output, cardiac index, and right ventricular stroke work index which were subjectively and objectively well tolerated in those patients studied. Ease and comfort of cannulation of these fistulas for blood sampling, infusion chemotherapy, and hemodialysis were uniformly acceptable to both nurses and patients.Central high flow arteriovenous fistulas have proved a safe, durable, well tolerated means of providing vascular access in patients whose usual routes have been exhausted but who remain candidates for cyclic infusion chemotherapy or chronic hemodialysis.     

Chondrosarcoma of the trapezium: a case report.

Roentgenograms of a 46-year-old Caucasian man with progressive swelling and pain at the base of the thumb who had been treated for arthritis showed an enlargement of the trapezium. The entire bone and surrounding ligaments were removed and an iliac bone graft was used to fuse the trapezoid to the first metacarpal. Sections of the tumor were diagnosed as chondrosarcoma. No recurrence is apparent 3 years after excision.     

Traumatic injuries of the pancreas

Traumatic injuries of the pancreas have evolved from an uncommon encounter of even wartime wounds to a relatively common injury of today's civilian strife. A review of 448 patients sustaining pancreatic trauma demonstrated that the pancreatic injury alone contributes little to immediate or late mortality but is frequently a source of postoperative morbidity. Complications of pancreatic injury comprise almost half of those observed after trauma in such patients, but for the most part are self-limited and easily cared for. Survival among patients sustaining pancreatic injury depends mainly upon the degree of success with which the multiple associated injuries can be managed.