Paced latissimus dorsi used for dynamic cardiomyoplasty of left ventricular aneurysms

Two patients are described, each with a large left ventricular aneurysm and severe coronary artery disease, and each with an ejection fraction lower than 30% and in congestive heart failure. In both, the left latissimus dorsi (LD) muscle was used in the repair of the ventricular aneurysm because preoperative studies demonstrated that there was concomitant coronary artery disease, and there was a strong suggestion that resection of the entire aneurysm would seriously compromise the residual ventricular capacity. One patient had an 18-year history of coronary occlusion with two infarctions. A large, calcified ventricular aneurysm developed, and despite vigorous medical treatment, intractable congestive heart failure and angina persisted. The diffuse coronary artery disease made this patient a poor candidate for bypass grafting. The other patient sustained an acute myocardial infarction 5 months prior to operation. The left anterior descending coronary artery was totally occluded, and a large apical aneurysm developed along with an akinetic anterior wall and septum. After his heart attack, the patient had progressive dyspnea on exertion. Following operation in both patients, the transpositioned LD, then a component in the repair of the left ventricular wall, was electrically trained to synchronously contract with each systole, driven by a standard dual-chamber cardiac pacemaker. Steady improvement and a return to normal activities were observed in both patients. There was an indication of improved ejection fraction with synchronous contraction of the skeletal muscle.     

Left atrial to femoral arterial bypass using the biomedicus pump for operations of the thoracic aorta

Left atrial to left femoral arterial bypass is an approach to operations of the thoracic aorta dating back to the late 1950s. Since that time, various modifications of the basic bypass circuit have evolved. In addition, temporary bypass shunts have also been described in a variety of positions. The goals of bypass of the thoracic aorta regardless of the technique include prevention of distal hypoperfusion, which can lead to paraplegia, limb loss, multiple organ failure, and sometimes death. Recently, there have been reports of the use of the biomedicus centrifugal pump in bypass circuits of the thoracic aorta. Our series, as well as the success of others, using this variation of a traditional bypass circuit of the thoracic aorta, establishes the biopump's capability of minimizing inherent complications in the bypass circuit.     

Intralobar sequestration. A missed diagnosis

Intralobar pulmonary sequestration is an uncommon but distinct clinical entity that may be the unrecognized cause of recurrent pulmonary infections. Between 1967 and 1987, 10 patients, ranging in age from 5 to 39 years, were found to have an intralobar sequestration. Nine patients (90%) had a history of recurrent pulmonary infections, chronic cough, and intermittent fevers. One patient was asymptomatic. Many patients had been treated with antibiotics on numerous occasions. The delay in diagnosis varied between 3 months and 7 years (mean delay, 1.5 years). The chest roentgenogram was abnormal in all patients. The intralobar sequestration was present in the left lower lobe in 7 patients and the right lower lobe in 3 patients. Bronchography was abnormal in 4 patients in whom it was done. Bronchoscopy was performed in 7 patients, but it was only helpful in excluding other diagnoses. Preoperative thoracic arteriography in 9 patients visualized the systemic arterial supply from the thoracic or abdominal aorta to the intralobar sequestration and helped prevent any catastrophic surgical bleeding. A lobectomy was performed in 9 patients and a segmentectomy in 1 patient without morbidity or mortality. In patients with recurrent infections in the same lower lobe, a high index of suspicion for an intralobar sequestration should prompt early diagnostic arteriography and, if confirmed, early operative intervention.     

Sudden cardiac death

This article reviews the epidemiology of sudden cardiac death, and outlines suggested management of patients who are successfully resuscitated from cardiac arrest. Emphasis is placed on the favorable impact of newer means of therapy on the very high recurrence rate using empiric antiarrhythmic treatment.     

Revascularization of a symptomatic pseudoaneurysm of the anterior tibial artery

Traumatic pseudoaneurysms of the peripheral arterial vasculature occur infrequently. The majority of the experience with these lesions is from this century's wartime experience. Pseudoaneurysms of the tibial vessels comprise only three to seven per cent of all pseudoaneurysms and only seven cases of anterior tibial artery pseudoaneurysms have been reported in the American and British literature since World War II. A high index of suspicion must be maintained for prompt detection of these lesions. Formerly, injuries of the tibial vessels were managed by nonoperative measures or exploration and arterial ligation. These approaches were met with varying results. The evolution of current vascular surgical techniques allows successful reconstruction of these vessels. We wish to report a successful method of repair of symptomatic pseudoaneurysm of the anterior tibial artery using a saphenous vein interposition graft. This technique restored arterial continuity and allowed maximal opportunity for limb salvage. Additional management techniques are discussed and compared in order to improve rapid diagnosis and provide efficient treatment.