Anomalous aortic origin of the right and left pulmonary arteries in a normally septated truncus arteriosus.

The first reported case of anomalous origin of the right and left pulmonary arteries with a normally septated truncus arteriosus is presented. Embryologic mechanisms are discussed, and a possible explanation for the development of the anomaly is advanced. Surgical correction was unsuccessful in this case, but is feasible and mandatory for long-term survival.

Concomitant coronary artery bypass and major noncardiac surgery.

Concomitant cardiac procedures performed in conjunction with coronary bypass have become commonplace, but not concomitant noncardiac procedures. Bernhard and associates were the first to report concomitant coronary bypass and carotid endarterectomy. This series, begun in 1971, consists of 71 noncardiac procedures performed concomitantly with coronary bypass on 68 patients. Thirty-seven procedures were performed for associated vascular disease, including carotid endarterectomy (25 patients) and resection of abdominal aortic aneurysm (three patients). Other concomitant problems included are thymoma, bronchogenic carcinoma, and hiatal hernia. The operative mortality rate of 2.9 percent compares very favorably with that of 1.7 percent in our group of patients having isolated coronary artery bypass. A plea is made for consideration of concomitant surgery in patients with operable coronary heart disease who have an additional serious noncardiac surgical disease.

Cardiopulmonary bypass in anesthetic management of resection. Its use for severe tracheal stenosis.

On initial evaluation, two patients were found to be in severe respiratory distress from tracheal obstruction. One patient had late obstruction after a crushing injury to the chest, whereas the other had subtotal tracheal obstruction from a carcinoid adenoma. In each case, the state of the patient seemed to preclude safe anesthetic induction with an endotracheal tube as the sole means of oxygenating the patient. Partial cardiopulmonary bypass provided an adjunct to ensure adequate oxygenation for tracheal resection. Consideration for the use of this technique is recommended in similar circumstances.

Aprotinin for primary coronary artery bypass grafting: a multicenter trial of three dose regimens.

BACKGROUND: High-dose aprotinin reduces transfusion requirements in patients undergoing coronary artery bypass grafting, but the safety and effectiveness of smaller doses is unclear. Furthermore, patient selection criteria for optimal use of the drug are not well defined. METHODS: Seven hundred and four first-time coronary artery bypass grafting patients were randomized to receive one of three doses of aprotinin (high, low, and pump-prime-only) or placebo. The patients were stratified as to risk of excessive bleeding. RESULTS: All three aprotinin doses were highly effective in reducing bleeding and transfusion requirements. Consistent efficacy was not, however, demonstrated in the subgroup of patients at low risk for bleeding. There were no differences in mortality or the incidences of renal failure, strokes, or definite myocardial infarctions between the groups, although the pump-prime-only dose was associated with a small increase in definite, probable, or possible myocardial infarctions (p = 0.045). CONCLUSIONS: Low-dose and pump-prime-only aprotinin regimens provide reductions in bleeding and transfusion requirements that are similar to those of high-dose regimens. Although safe, aprotinin is not routinely indicated for the first-time coronary artery bypass grafting patient who is at low risk for postoperative bleeding. The pump-prime-only dose is not currently recommended because of a possible association with more frequent myocardial infarctions.

Repair of acute dissection of the ascending aorta, associated with coarctation of the thoracic aorta in a Jehovah's Witness.

A twenty-year-old white man, with acute dissection of the ascending aorta, underwent emergency resection with dacron graft replacement, utlizing cardiopulmonary bypass. Subsequent repair of coarctation of the thoracic aorta was performed. No blood was administered due to the patient's religious preference. The problems of emergency surgery in Jehovah's Witness patients are discussed.

Arteriosclerotic aneurysms of the coronary arteries: surgical treatment.

We infer from our experience in over 4,000 revascularization procedures that true arteriosclerotic aneurysms of the coronary arteries are even more rare than reported in the literature, that such aneurysms usually occur in association with severe occlusive disease of the coronary arteries, and that the best surgical approach is to excise or ligate the aneurysm rather than leave it in continuity with coronary arterial circulation and risk complications. We present both rationale and technique in support of this more radical therapeutic approach.