Repair of aneurysmal aortic coarctation in an octogenarian.

An 80-year-old man presented with a descending thoracic aortic aneurysm. Computed tomography and aortography revealed a large aneurysm and tight aortic coarctation. This was successfully repaired with an interposition prosthesis.

Diagnostic and therapeutic video assisted thoracic surgery (VATS) following chest trauma.

OBJECTIVE: Thoracic injury remains a major source of morbidity and mortality in urban trauma centers. With the advent and increasing expertise in video assisted thoracic surgery, this modality has become an attractive alternative in the management of patients with thoracic injury. This report will review our experience with video assisted thoracic surgery at a level I trauma center and attempt to further delineate the indications for and timing of thoracoscopy in thoracic trauma. METHODS: We identified 16 patients who had undergone video assisted thoracic surgery following chest trauma between July 1991 and June 1994. There were 15 penetrating and one blunt trauma. All 16 patients were initially treated with tube thoracostomy. From 0-20 days post-injury, video assisted thoracic surgery was attempted with either diagnostic or therapeutic intentions. RESULTS: Twelve of the 16 patients (75%) had successful thoracoscopy. Three patients had diaphragmatic injury excluded and nine patients had successful evacuation of clotted hemothoraces. Evacuation of clotted hemothorax up to 7 days post-injury was safe and easily accomplished. Four patients (25%) had unsuccessful thoracoscopy and were converted to standard thoracotomy; failure was attributed to either suboptimal single lung ventilation or severe pleural inflammatory reaction. The only death in the entire group occurred 10 days after a thoracotomy for retained hemothorax. The median post-operative hospital stay following successful video assisted thoracic surgery was 3.5 days. CONCLUSIONS: Video assisted thoracic surgery can be utilized as an effective and safe method for the initial diagnostic evaluation and surgical management of stable patients with penetrating thoracic trauma.

Venous cannula obstruction by Swan-Ganz catheter during cardiopulmonary bypass.

During a routine coronary revascularization procedure in a 51-year-old man, venous return was suddenly interrupted. The venous cannula was rapidly removed, revealing the pulmonary artery catheter wrapped around it. The catheter also had entered the lumen of the cannula, and the inflated balloon completely obstructed the venous return. The prompt removal and reinsertion of the venous cannula resulted in uneventful recovery of the patient.

Trauma life support education: a didactic and caprine laboratory course for Nigerian physicians.

The purpose of this study was to introduce the principles of initial hospital assessment and treatment of injured patients, tailored to the facilities and resources available in Nigeria. A 3-day didactic and laboratory course was presented by four trauma surgeons. The didactic session stressed the initial assessment and treatment of injured patients. The caprine laboratory taught the performance of common resuscitation manoeuvres: cricothyroidotomy, tube thoracostomy, i.v. cut-down, diagnostic peritoneal lavage, etc. The mean pre-course test score was 49.3 per cent and the mean post-course test score was 69.5 per cent; 93.5 per cent of the 124 participants increased their test scores. This represents a significant increase in knowledge in Nigerian physicians. Academic medical centres are encouraged to make such courses available in developing countries.

Chest wall hamartoma in an adult: an unusual chest wall tumor.

An asymptomatic intrathoracic mass was demonstrated on imaging studies in an adult. Operative removal was accomplished and it proved to be an extrapulmonary hamartoma arising from the soft tissue of the chest wall. This represents a rare location of this benign tumor in an adult.

Coronary artery endarterectomy for retrieval of entrapped percutaneous angioplasty catheter.

A 70-year-old patient underwent percutaneous transluminal coronary angioplasty of a calcified tight mid-right coronary artery lesion, when the balloon burst and could not be retrieved. Even on cardiopulmonary bypass, the catheter could not be extracted through a proximal aortotomy. The patient had a distal reversed saphenous vein graft inserted into the right coronary artery. The catheter was ultimately removed after an endarterectomy of the calcified lesion.

Combined conventional mechanical and ultrasonic debridement for aortic valvular stenosis.

Ultrasound decalcification of aortic valve stenosis was performed in 31 patients. There were 16 men and 15 women with a mean age of 71.03 +/- 9.6 years (range, 51 to 89 years). Each had severe calcific aortic stenosis with an aortic valve gradient greater than 40 mm Hg, aortic valve area (AVA) less than 0.6 cm2, and no serious insufficiency. Feasibility of aortic valve debridement was determined under direct vision. Intraoperative epicardial or transesophageal color Doppler two-dimensional echocardiography was used before and after the aortic valve debridement to evaluate aortic cusp motion and aortic regurgitation. Direct transseptal aortic valve gradient was measured on all patients before and after aortic valve debridement, and the AVA was determined. Aortic valve debridement was performed as the primary procedure in 17 cases and combined with other cardiac procedures in 14 patients. Preoperative aortic valve gradient was reduced from 72.5 +/- 22.5 mm Hg (range, 40 to 130 mm Hg) to 15.5 +/- 11.9 mm Hg (range, 2 to 50 mm Hg), and the average AVA of 0.41 +/- 0.10 cm2 (range, 0.22 to 0.63 cm2) was increased to 1.55 +/- 0.58 cm2 (range, 0.65 to 3.50 cm2) after ultrasound decalcification. There were two early deaths in octogenerian, high-risk patients, and two late deaths (6.45% early and 6.45% late mortality), none of them related to AVD. Postoperative follow-up included clinical evaluation and color Doppler echocardiography every 6 months. The aortic valve gradient was measured using a continuous-wave Doppler probe, and the AVA was calculated by the simplified continuity equation: AVA = aAOA x vLVOT/vAV.(ABSTRACT TRUNCATED AT 250 WORDS)

Transthoracic intraaortic balloon pump support: experience in 39 patients.

From June, 1982, through July, 1985, 39 (1.5%) of 2,570 patients undergoing open-heart procedures required insertion of a transthoracic intraaortic balloon pump (IABP). In all of these patients, a percutaneous attempt failed or was contraindicated. There were 24 (62%) men and 15 (38%) women. The mean age was 64.9 years. Five patients (13%) sustained complications potentially related to the transthoracic IABP. They included mediastinal infection in 1 patient (2.5%), balloon rupture in 2 patients (5%), and cerebrovascular accidents in 4 patients (10%). The overall survival was 44%. Survival for the group of patients weaned from transthoracic IABP support was 17 (81%) of 21. There were no deaths directly related to the transthoracic IABP. The transthoracic IABP was removed under local anesthesia without sternotomy in 19 (90%) of the patients weaned and with formal sternotomy in the remaining 2 (9%). In a select group of patients requiring intraaortic balloon counterpulsation, the use of the transthoracic IABP is a reasonable second choice for patients in whom other methods of balloon support are not feasible.

Disc embolization of Björk-Shiley mitral prosthesis without strut fracture.

Strut fracture with subsequent embolization of the Björk-Shiley mitral prosthesis is a rare but recognized complication. A case of disc embolization without strut fracture was managed successfully by early surgical intervention. The preoperative chest x-ray film demonstrating apparently intact major and minor struts underscores the importance of a high index of suspicion to make an early diagnosis.

"Tire patch" angioplasty: a new method of arterial repair.

A method of controlling a problematic aortotomy suture line using an onlay patch of polytetrafluoroethylene (Gore-Tex) is described. This method has been used successfully in several instances with good control of bleeding and no complications.

Endotracheal intubation using percutaneous retrograde guidewire insertion followed by antegrade fiberoptic bronchoscopy.

Although endotracheal intubation can usually be performed readily by many medical and paramedical personnel, it may be very difficult in situations such as trauma, hemorrhage, or deformity. We inserted an endotracheal tube over a retrograde guidewire in a patient with a cervical deformity. Published reports of retrograde intubation are reviewed.

Reoperation for stenotic saphenous vein bypass grafts without cardiopulmonary bypass or shunt.

From October 1982 through February 1985, six patients have undergone seven reoperative revascularization procedures for stenosis of coronary artery vein bypass grafts without the use of cardiopulmonary bypass or intraoperative shunt. All patients had prior coronary artery saphenous vein bypasses, ranging from 2 months to 5 years preoperatively. All patients survived reoperation and there was no morbidity. Patients have been followed-up to 26 months. One patient underwent postoperative cardiac catheterization at 1 year, which revealed a patent interposition graft, and one patient had a second operation for restenosis of a vein graft. To decrease the risk of morbidity and mortality in reoperative procedures for saphenous vein graft stenosis, a technique is described that avoids the use of cardiopulmonary bypass or intraoperative shunt. This technique has been used successfully for seven reoperative revascularization procedures and is recommended for selected cases.

Effect of phentolamine in controlling temperature and acidosis associated with cardiopulmonary bypass.

This study assessed the effects of phentolamine on rewarming patterns and metabolic acidosis in 37 patients subjected to hypothermia during cardiopulmonary bypass for the performance of aortocoronary bypass grafting. An additional 16 patients undergoing the same surgery received no phentolamine and served as a control group. In all patients, sodium bicarbonate (44.6 mEq) was administered only when the negative base excess was 3.0 mEq/L or greater. Sixty-eight percent of the patients receiving phentolamine and 56% of the control patients exhibited a uniform rewarming pattern in which the rectal, hand, and foot temperatures increased in parallel. In 32% of the patients receiving phentolamine and in 44% of the control patients, rectal and hand temperatures increased more than foot temperature during rewarming. Analysis of base excess values in the subgroups of patients with similar rewarming patterns indicated that base deficits were significantly decreased in patients receiving phentolamine. Phentolamine administration was also associated with significantly lower blood lactate levels and sodium bicarbonate requirements, as well as improvements in overall appearance and mental status. These data suggest that the routine use of phentolamine in patients undergoing cardiopulmonary bypass may be associated with more uniform body cooling and rewarming and improved tissue perfusion.

A comparison of Blalock-Taussig, Waterston, and polytetrafluoroethylene shunts in children less than two weeks of age.

Results obtained with Blalock-Taussig, Waterston, and polytetrafluoroethylene (PTFE) shunts were compared in 67 cyanotic infants less than 2 weeks of age. A different shunt was preferably used at each of three institutions. The incidences of early shunt failure (3 out of 21, 14%), mortality after revision of early shunt failure (0 out of 3), and overall hospital mortality (1 out of 21, 5%) were all lowest for the PTFE shunt. Incidence of congestive heart failure secondary to excessive flow was comparable for the Blalock-Taussig and PTFE shunts, both of which were lower than the Waterston shunt. Cumulative probabilities of late shunt adequacy were calculated for hospital survivors. At 1 year, all shunts provided comparable adequate palliation (greater than 80%). Probability of late shunt failure was significantly higher (p = 0.04) for the PTFE shunt at 3.5 years. Results suggest that the PTFE shunt may be the safest and most effective shunt in neonates, but that elective shunt replacement or total repair may be warranted in the first or second year of life.

Treatment of restenosis of coarctation by percutaneous transluminal angioplasty.

Percutaneous transluminal angioplasty (PTA) was used successfully to treat coarctation restenosis in seven patients. The patients were 10 months to 17 years old at the time of the angioplasty, and the initial coarctation repair had been performed 10 months to 16 1/2 years previously. PTA reduced the systolic pressure gradient across the coarctation from a mean of 58 mm Hg before the procedure to a mean of 13 mm Hg immediately after PTA. Follow-up has been from 1 to 14 months and indicates that the decrease in the systolic pressure gradient is persistent.

Left ventricular aneurysmectomy. Factors influencing postoperative results.

One hundred consecutive patients who underwent resection of aneurysms of the left ventricle were reviewed. Eighty-four of these patients had resection or plication of an aneurysm of the anterior left ventricular wall either alone or in combination with coronary artery bypass grafting. In 27 patients who had little or no congestive heart failure, the primary indication for operation was disabling angina pectoris. In them the early mortality was 4% and late mortality, 4%. In nine other patients the primary indication for operation was life-threatening ventricular arrhythmias. In this group the early mortality was 56% and late mortality, 0%. Severe congestive heart failure was the primary indication for aneurysmectomy in 48 patients. In these patients the early mortality was 21% and late mortality, 34%. When the primary indication for operation was severe congestive heart failure, overall survival and postoperative results were best in patients in whom the nonaneurysmal left ventricle had good function preoperatively and was supplied by coronary arteries either unobstructed or favorable for bypass grafting; results were poorest in those patients with three-vessel coronary artery disease who had impaired motion of the lateral left ventricular wall and distal lateral wall vessels that were unfavorable for bypass grafting. It is concluded that patients with left ventricular aneurysms form a heterogeneous group in which the prognosis varies markedly. The probability of a good postoperative result can be predicted by careful preoperative analysis of a patient's symptoms, ventricular function, and coronary artery anatomy.