Cardiogenic shock due to cardiac free-wall rupture or tamponade after acute myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock?

OBJECTIVES: We sought to compare the characteristics and outcomes of patients with acute myocardial infarction (MI) and cardiogenic shock (CS) caused by rupture of the ventricular free wall or tamponade versus shock from other causes. BACKGROUND: Free-wall rupture is a recognized cause of mortality in patients with acute MI. Some of these patients present subacutely, which provides an opportunity for intervention. Recognition of factors that distinguish them from the overall shock cohort would be beneficial. METHODS: The international SHOCK Trial Registry enrolled patients concurrently with the randomized SHOCK Trial. Thirty-six centers consecutively enrolled all patients with suspected CS after MI, regardless of trial eligibility. RESULTS: Of the 1,048 patients studied, 28 (2.7%) had free-wall rupture or tamponade. These patients had less pulmonary edema, less diabetes, less prior MI, and less prior congestive heart failure (all p < 0.05). They more often had new Q waves in two or more leads (51.9% vs. 31.5%, p < 0.04), but MI location and time to shock onset after MI did not differ. Of patients with rupture or tamponade, 75% had pericardial effusions. No hemodynamic characteristics identified patients with rupture/tamponade. Most patients with rupture/tamponade had surgery and/or pericardiocentesis (27/28); their in-hospital survival rate was identical to that of the group overall (39.3%). Women and older patients with rupture/tamponade tended to survive intervention less often. CONCLUSIONS: Free-wall rupture and tamponade may present as CS after MI, and survival after intervention is similar to that of the overall shock cohort. All patients with CS after MI should have echocardiography in order to detect subacute rupture or tamponade and initiate appropriate interventions.

Early mortality and morbidity of bilateral versus single internal thoracic artery revascularization: propensity and risk modeling.

OBJECTIVES: We examined whether bilateral internal thoracic artery (BITA) revascularization is associated with any increased in-hospital mortality and complications compared with single internal thoracic artery (SITA) revascularization. BACKGROUND: Despite proven long-term benefits, BITA revascularization has been slow to be adopted because of fear of increased early morbidity. METHODS: We evaluated 1,697 consecutive patients undergoing BITA (n = 867) or SITA (n = 830) revascularization. We used propensity score analyses and adjusted risk models to address differences between arms. RESULTS: There were 20 (2.3%) deaths in the BITA group versus 26 (3.1%) in the SITA group (odds ratio 0.73, p = 0.30). Propensity analysis identified several parameters that affected the decision to use BITA. Adjusting for propensity score and all potential risk factors, the odds ratio for death with BITA versus SITA was practically 1. Bilateral internal thoracic artery revascularization did not increase the number of in-hospital complications with the possible exception of deep sternal wound infections (11 [1.3%] vs. 3 [0.4%], p = 0.057). In multivariate modeling BITA increased the risk of deep sternal wound infections only in emergent cases and in older patients; the excess risk was negligible among 1,206 patients (71.1% of total) who did not have emergent revascularization and were < or =70 years old (risk difference 0.3%, p = 0.74). There was no difference in length of stay after adjustment for propensity factors (mean 11.3 vs. 11.7 days, p = 0.66). CONCLUSIONS: Bilateral internal thoracic artery revascularization grafting confers no increased risk for early death and does not prolong hospital stay. The small increase in the risk of deep sternal wound infections does not affect the majority of patients.

Homologous blood transfusion as a risk factor for postoperative infection after coronary artery bypass graft operations.

Homologous transfusions are immunosuppressive and associated with a higher risk of postoperative infection. In this retrospective analysis, we studied 238 consecutive patients who underwent first-time coronary operations by a single surgeon in 1988 to 1989 and collected clinical and laboratory data relevant to postoperative infections including pulmonary, urinary, and wound sites. Culture-proved postoperative infections occurred in 16 of the 238 patients (6.7%), with only 3 (1.3%) being deep sternal wound infections. Seven of 16 (44%) of the infections were away from the wound sites, suggesting that nonsurgical variables contributed to at least some infections. Factors significantly associated with an increased risk of postoperative infection by univariate analysis included female sex, diabetes mellitus, and transfusion dose. Infections occurred in 3.9% of patients receiving up to 2 units of red cells and whole blood, 6.9% receiving 3 to 5 units, and 22% of those receiving 6 units or more. Multiple linear and logistic regression analysis showed that transfusion dose was the most significant predictor of infection, days of fever, days of antibiotic therapy, and length of hospital stay. Homologous transfusion is associated (in a dose-dependent fashion) with a threefold to eightfold increased risk of postoperative infection in patients undergoing coronary artery operations. This increased risk of infection may be due to transfusion-induced immunosuppression of the patient.

Multiple aneurysms of the internal thoracic artery.

Nontraumatic aneurysms of the internal thoracic artery are rare. We report a case where multiple aneurysms of the right internal thoracic artery presented as an asymptomatic density on the chest radiograph. Operative findings and pathology are reviewed.

A late complication of tuberculous pericarditis after partial pericardial resection.

Tuberculous pericarditis is estimated to occur in 1% to 2% of cases of pulmonary tuberculosis. Despite adequate therapy, a subset of patients may eventually require pericardiectomy. Incomplete pericardial resections are associated with an increased incidence of late complications. We report a cutaneous sinus tract communicating with residual pericardium and a retrosternal abscess cavity 11 years after partial pericardial resection.

Successful repair of myocardial free wall rupture after thrombolytic therapy for acute infarction.

BACKGROUND: Controversy exists regarding the timing of thrombolytic administration and rupture rate. METHODS: Hospital records at St. Luke's-Roosevelt Hospital of the 4 study patients were reviewed and compared with those of 41 patients from a group of 537 patients concurrently admitted with a diagnosis of myocardial infarction (MI). RESULTS: Four patients experienced ventricular free wall rupture after having a MI between November 17, 1993, and July 28, 1995. All received tissue plasminogen activator. In 1 patient, pericardial effusion associated with a pseudoaneurysm was discovered in the operating room. The 3 others developed clinical pericardial tamponade before surgery. All 4 patients survived and left the hospital on postoperative days 10, 11, 11, and 82, respectively. During this same time period, 537 patients were admitted with MI, 41 of whom died; the study's 4 patients were compared with these 41. CONCLUSIONS: These data demonstrate that rupture of the ventricular free wall can occur early after thrombolytic therapy and may have a subacute course. Prompt diagnosis and surgery offer excellent chances of surviving this fatal condition.

Treatment of aortic coarctation by axillofemoral bypass grafting in the high-risk patient.

Operative correction of coarctation of the aorta has been performed for 45 years. Reoperation for recurrent coarctation is necessary in as many as 5% to 10% of patients. Repair of recurrent coarctation carries an operative mortality of between 5% and 10%. Coarctation repair involves an increased risk in patients with advanced age, recurrent coarctation, congestive heart failure, and pulmonary disease. We report 3 cases where axillofemoral bypass has been used to treat high-risk patients with aortic coarctation. Two patients had had previous coarctation repair in addition to serious medical problems. Another patient had suffered three myocardial infarctions and had disabling congestive heart failure. All patients had an immediate marked decrease in their preoperative peak systolic pressure gradient across the coarctation. Systemic hypertension and symptoms of congestive heart failure were improved in all patients. The length of follow-up was 15 months, 8.5 years, and 10.5 years. Reassessment with noninvasive vascular segmental pressure studies with and without an exercise component showed no recurrence of the pressure gradient. This procedure should be considered when treating coarctation of the aorta in the high-risk adult.

Communicating bronchopulmonary pancreatic foregut malformation.

Bronchopulmonary foregut malformations include intralobar and extralobar pulmonary sequestrations, bronchogenic cysts, and communicating bronchopulmonary foregut malformations (CBPFM). These malformations, formes frustes, originate as developmental abnormalities of ventral foregut budding of the tracheobronchial tree or the gastrointestinal tract. The communication's patency with the parent viscus determines if a contained malformation occurs, or if an abnormal communication persists as a CBPFM. This case demonstrates a unique example of a CBPFM in which the main pancreatic duct communicated with pulmonary parenchyma through a retroperitoneal fistula.

The influence of demographic factors on seatbelt use by adults injured in motor vehicle crashes.

This study determined demographic factors associated with reported seatbelt use among injured adults admitted to a trauma center. A retrospective chart review was conducted including all patients admitted to a trauma center for injuries from motor vehicle crashes (MVC). E-codes (i.e. ICD-9 external cause of injury codes) were used to identify all patients injured in a MVC between January 1995 and December 1997. Age, sex, race, residence zip code (i.e. a proxy for income based on geographic location of residence), position in the vehicle, and seatbelt use were obtained from the trauma registry. Forward logistic regression was used to identify significant predictors of seatbelt use. Complete data was available for 1366 (82%) patients. Seatbelt use was reported for 45% of patients under age of 25 years, 52% of those 25-60 years, and 68% of those over 60 years. Overall, seatbelt use was reported for 45% of men and 63% of women, as well as for 56% of Caucasians (i.e. Whites) and 34% of African Americans. In addition, seatbelt use was reported for 33% of those earning less than $20,000 per year and 55% of those earning over $20,000. Finally, seatbelt use was reported for 57% of drivers and 43% of passengers. Logistic regression revealed that age, female gender, Caucasian race, natural log of income, and driver were all significant predictors of reported seatbelt use. These results show that seatbelt use was more likely to be reported for older persons, women, Caucasians, individuals with greater incomes, and drivers. Seatbelt use should be encouraged for everyone; however, young people, men, African Americans, individuals with lower incomes, and passengers should be targeted specifically.

A case of massive thymolipoma.

A massive anterior mediastinal tumor was discovered in a 9-year-old girl with long-standing symptoms of asthma. Preoperative computed tomography (CT) scan and magnetic resonance imaging (MRI) results suggested the presence of a thymolipoma, a rare benign tumor of the thymus. Few cases have been reported in the literature, although the histological and radiographic features have been well described. This case confirms previously reported characteristics and also illuminates new aspects of clinical presentation and perioperative management.

Inflammatory aneurysm of the ascending aorta; an unreported entity.

A 69-year-old woman with an enlarging ascending aortic aneurysm is presented. At operation, the patient was noted to have extensive peri-aneurysmal fibrosis and inflammation with a 1 cm thick aneurysm wall. Pathologic examination was consistent with inflammatory aneurysm. Inflammatory aneurysms of the thoracic aorta are uncommon and this may be the first patient with this process involving the ascending aorta with both operative and pathologic findings.

"Band aid" surgery: upper sternal split incision for valve surgery in adults. A modified technique.

A limited 10 cm upper sternotomy to the level of the third right intercostal space with preservation of the entire length of the left half of the sternum (quarter sternotomy) allows: 1) exposure for aortic valve surgery; 2) utilization of standard equipment and cannulation techniques; 3) preservation of both internal thoracic arteries and 4) early discharge from the hospital. Three patients, all female, aged 45, 62 and 67, two with severe aortic insufficiency and one with severe aortic stenosis, underwent replacement. In two, a St. Jude's valve and in one, a Baxter pericardial valve were used. In addition, aortic decalcification-endarterectomy was carried out in one and re-exploration in another. All patients were discharged at 4 days, impressed by their "Band-Aid Surgery". Improved patient mobility and earlier recovery of ventilatory function are possibly related to this more stable form of limited sternotomy.

Concurrent right atrial myxoma and malignant lymphoma.

Atrial myxomas are the most common primary tumor of the heart. We report an unusual case where an incidentally found right atrial myxoma was associated with a malignant lymphoma. Surgical management of the concurrent problems is discussed as well as a review of pertinent literature and efficacy of diagnostic modalities.

Transmural myocardial infarction with coexisting critical aortic stenosis as an etiology for early myocardial rupture.

Myocardial rupture is the most important cause of post-infarct sudden death after myocardial infarction other than shock and dysrhythmias. Usually unrecognized, pseudoaneurysm formation is a delayed consequence of myocardial rupture in a small portion of patients who will remain at high risk for late rupture and death. Clinical studies have defined a profile of the patient who is at increased risk for post-infarct myocardial rupture. We believe that an additional factor, ventricular outflow tract obstruction, may add to the risk of having a post infarct rupture. A high degree of suspicion by the clinician accompanied by the timely performance of diagnostic tests may help to decrease the mortality from this catastrophic event.

Initial clinical experience with rectus sheath grafts in congenital heart defects.

This study reports on the initial clinical experience using anterior rectus sheath as potentially growing graft material in congenital heart lesions. The first seven patients with complex congenital lesions requiring a rectus sheath graft because of inadequate available pericardium are reviewed. The initial operations were: TOF (unicusp pulmonary valve) (re-op), two Konno procedures (one VSD and one RV patch), two arterial switch procedures for TGA (neoaortic augmentation), two Fontan (re-op) atrial augmentation patch and pulmonary arterioplasty (re-op). Ages ranged from 1 week to 15 years. Follow-up ranged from 1 to 72 months and included open visual inspection at reoperation in 5 cases, angiography in 3 cases, and echocardiography in 4 cases. One early respiratory death occurred in the fourth postoperative week. So far no early bleeding from rectus sheath patches, infection, aneurysmal dilatation, or scar contraction was observed. No manifestation of peripheral emboli was seen. Hernias of the harvest site were absent. We concluded that in absence of pericardium and in areas where future cicatrization or aneurysmal dilatation is undesirable, anterior rectus sheath appears to be a reasonable alternative.

Possible intra-aortic balloon pump "function-related" mechanism of embolic events in patient with protruding atheroma in the thoracic aorta.

A possible new functional mechanism of atheromatous embolus is presented resulting from reversed aortic blood flow during diastolic augmentation by balloon counterpulsation. This mechanism is different from mechanical disruption during insertion. Despite this, intra-aortic balloon remains an important asset in the management of hemodynamically challenged patients.