Sodium nitroprusside and propranolol therapy for management of postcoarctectomy hypertension.

The cause of hypertension following satisfactory repair of coarctation of the aorta remains obscure. Most agree that significant elevation of the blood pressure after operation demands therapy. Previously the combination of trimethaphan and reserpine was utilized, but the incidence of adverse reactions was high. We recently have used the regimen of sodium nitroprusside and propranolol in six patients with gratifying results. This report reviews the problem as well as our use of nitroprusside and propranolol in managing hypertension following coarctation repair.

The cost of simultaneous surgical standby for percutaneous transluminal coronary angioplasty.

From November, 1980, to May 1985, 699 patients have undergone percutaneous transluminal coronary angioplasty of 784 lesions at our institutions. Simultaneous surgical standby was available on all cases. One hundred twenty-four patients (18%) underwent immediate myocardial revascularization; 45 (6%) were operated on because the lesion could not be dilated. Seventy-nine patients (11%) underwent immediate operation for an acute complication of angioplasty: coronary occlusion in 45, dissection in 29, coronary perforation in three, and atrial perforation in one. Fourteen patients (18%) required cardiopulmonary resuscitation en route to the operating room, and 10 patients (20%) had insertion of an intra-aortic balloon pump in the cardiac catheterization laboratory. The average time from complication to reperfusion was 87 minutes, ranging from 40 to 165 minutes. An average of 2.0 grafts per patient (ranging from one to five grafts per patient) were performed. Of those 79 patients who underwent operation for an acute complication, one died (1.3%), 31 patients (39%) had a myocardial infarction according to enzyme criteria (creatine kinase-myocardial band greater than 40 IU), and 17 patients (22%) had new Q waves on the electrocardiogram. Good results are related to minimizing the time the myocardium is ischemic. No patient in whom reperfusion was begun in less than 75 minutes had a Q wave infarction or a creatine kinase-myocardial band level greater than 40 IU. Simultaneous surgical standby is the only method allowing immediate access to surgical facilities. A standby team of eight persons and equipment were immediately available for emergency bypass grafting for an average of 3.6 hours (range 1.3 to 5.4 hours per angioplasty attempt). The patient charges for this simultaneous standby were $632.00 per angioplasty attempt, or $442,278.00 for the entire series. The actual cost of the standby was over $1,700.00 per attempt totaling $1,188,843.00 for the 699 patients. This underestimation of the cost of surgical standby has occurred in other series, because little mention has been made of this cost in the published reports on the cost effectiveness of angioplasty. In terms of time demands, over 2,500 hours were spent by surgeons standing by for the 699 attempts. Simultaneous surgical standby is the most effective means of limiting the time the myocardium is ischemic after an angioplasty complication. However, this method is costly, necessitating more of a financial and time commitment than generally anticipated. Future studies of the cost effectiveness of angioplasty should include the cost of surgical standby with accurate per-patient cost accountability.

Unrecognized intraoperative torsion of the lung.

A case is presented of clockwise torsion of the entire left lung on its bronchovascular pedicle during intraoperative manipulations for a nonpulmonary procedure. The grave consequences are presented as well as a discussion of the mechanism of injury and a review of the pertinent literature. To our knowledge, this is the first such case reported.

A simplified method of ligation of patent ductus arteriosus in premature infants.

A clip technique for ligation of the ductus arteriosus in premature infants is presented.