The limited utility of fibrinogen I 125 leg scanning.

Using venography as the reference procedure, this study examined the utility of fibrinogen I 125 scanning for the detection or demonstration of deep venous thrombosis. The results demonstrate the inability of leg scanning to detect accurately the presence or absence of thrombi in the deep venous system. Most striking was the lack of sensitivity of this procedure in areas where the propensity for embolization is greatest. Sensitivity is extremely low in the anatomic areas where leg scanning demonstrates reasonable specificity. The results are nearly identical in the extremity not operated upon. The validity of all prior studies relying heavily or exclusively on 125I leg scans to determine the presence or absence of thrombi must be critically reassessed.

Detection of covert myocardial sarcoidosis by scalene node biopsy.

The antemortem diagnosis of myocardial sarcoidosis is rare in patients without overt signs of the disease. Two patients are presented to alert physicians to the value of early scalene node biopsy when sarcoidosis could be the cause of marked disturbances in cardiac conduction. The first patient, aged 29 years, had first, second, and third degree atrioventricular block and intermittent left and right bundle-branch block; the second, aged 59 years, had second degree atrioventricular block and complete right bundle-branch block. Both had diagnoses of sarcoidosis based on scalene node biopsy. The cardiac conductive disturbance improved, and the symptoms disappeared with steroid therapy.

Importance of preoperative myocardial glycogen levels in human cardiac preservation. Preliminary report.

One hundred seventeen patients undergoing elective coronary bypass were divided into four groups according to prebypass myocardial glycogen levels and the use of potassium chloride cardioplegia. Myocardial glycogen levels were enhanced with a preoperative fat loading diet and overnight glucose loading. The control group (n = 27) which had mean cardiac glycogen levels of 750 mg/100 gm heart weight and no cardioplegia, had a transmural myocardial infarct rate of 14.4%; 35% had severe atrial arrhythmias 65% had severe ventricular arrhythmias, and 31% had severe vasopressor dependence. The group (n = 30) with low cardiac glycogen (736 mg/100 gm) and with potassium chloride cardioplegia had an infarct rate of 6.4%; 6.7% had severe atrial arrhythmias, 18% had severe ventricular arrhythmias, and 16.7% had severe vasopressor dependence. However, the group (n = 26) which had high cardiac glycogen levels (1,208 mg/100 gm) and no cardioplegia had no myocardial infarctions; 3.8% had severe atrial arrhythmias, 27% had severe ventricular arrhythmias, and only 7.8% had severe vasopressor need. The group (n = 34) which had high glycogen levels (1,516 mg/100 gm) and potassium chloride cardioplegia did best of all with no myocardial infarctions or no severe atrial arrhythmias; 14% had severe ventricular arrhythmias and 2.81% severe vasopressor need. The lessening of vasopressor dependence and severe atrial and ventricular arrhythmias were significant by chi square contingency tables at p less than 0.05 and p less than 0.001, respectively. One cardiac-related death each occurred in the two groups with low glycogen and none in those with high glycogen levels. This suggests that better preoperative cardiac nutrition as represented by enhanced cardiac glycogen helps that heart tolerate anoxic stress whether cardioplegia is utilized or not and is additive to potassium chloride cardioplegia.

Distal propulsion of vena cava umbrella by cardiac massage.

Distal propulsion of a 28 mm umbrella filter from vena cava to femoral vein occurred in a 75-year-old woman during external cardiac massage. After cardiac massage, filter position must be checked roentgenographically. Optimal management of distal migration might include placement of a second umbrella to prevent recurrent emboli and proximal migration of the dislodged umbrella.

Open pulmonary biopsy. Nineteen-year experience with 416 consecutive operations.

Four hundred and sixteen open pulmonary biopsies through limited thoracotomies are reported. Tissue sufficient for diagnosis was obtained in all cases. Case selection, operative technique, spectrum of diagnoses, complications, and comparisons with other techniques are defined. Diagnoses by category were as follows: occupational, 105 patients (25 percent); neoplastic disease, 80 patients (19 percent); specific histologic diagnosis, (ie, sarcoidosis), 70 patients (17 percent); specific infection, 23 patients (6 percent); vascular diagnosis, 16 patients (4 percent); and nonspecific pulmonary disease, 122 patients (29 percent). Pneumothorax, minor in most cases, was the most common complication. It occurred in 97 (23 percent) of the patients, but only 24 (6 percent) required the placement of a chest tube. Pleural effusion occurred in 106 patients (25 percent) and was minor. Hemothorax occurred in two (0.5 percent) and superficial wound infection in three (0.7 percent). Overall mortality was 4.5 percent (19 patients). Only two deaths (0.4 percent) were related to the procedure. Open pulmonary biopsy remains our diagnostic method of choice in diffuse lung disease of undetermined etiology.

The coin lesion story: update 1976. Twenty years' experience with thoracotomy for 179 suspected malignant coin lesions.

We reviewed 179 patients who had undergone thoracotomy and resection of a suspected malignant coin lesion of the lung over the past 20 years to see if a policy of early thoracotomy was therapeutically valid. The average diameter of all lesions was 1.6 cm; the average diameter of 27 malignant lesions (15 percent) was 1.8 cm. Follow-up of the 27 patients with malignant neoplasms was 100 percent. The present survival rate of the 19 patients with primary lung cancer is 89 percent (17/19). Of 12 cases of primary lung cancer followed for five years, ten (83 percent) survived. The five-year survival of the eight patients with metastatic lesions was 25 percent (2/8). There were no postoperative deaths and few serious postoperative complications (four patients or 2 percent). Very small primary lung cancers detected and treated early do have the same poor prognosis as larger primary cancers.

All-artery multigraft coronary artery bypass grafting with only internal thoracic arteries possible and safe: a randomized trial.

BACKGROUND: The internal thoracic artery (ITA) bypass to the left anterior descending coronary artery is of proven benefit in multigraft coronary artery bypass. Total ITA grafts, if reoperation is averted by avoiding saphenous vein grafts (SVGs), are attractive. The safety of the total ITA graft operation (all-ITA) is a concern. METHODS: A randomized trial of multiple-ITA bypass graftings with the use of bilateral sequential ITA without SVGs was performed. Control patients received 1 ITA plus SVG. Inclusion criteria were those used in the Coronary Artery Surgery Study, extended to age 76 years, and any angina class, except emergent. One hundred sixty-two patients were randomized (81 patients per group) from January 1, 1990, to December 31, 1994. RESULTS: Baseline traits were similar as were cross-clamp times, pump times, and number of arteries bypassed (average, 4.3 arteries). Patients who received multiple ITA grafts had no myocardial infarctions, per reference laboratory. One patient died, and 2 patients returned for bleeding. The ITA-SVG group had similar results. The all-ITA group experienced successful completion in 93% of cases. Complications did not differ from control patients. CONCLUSIONS: Early and 5-year outcomes were not different between the all-ITA group and the ITA with SVGs group. We believe experienced surgeons can safely extend the ITA to multibypass coronary artery bypass without use of SVG to achieve an all-ITA operation.

What is the probability that coronary artery surgery prolongs life?

Two-hundred and nine male patients who had coronary artery surgery from 1972 to 1974 at the Marshfield Clinic (MC) were compared with Veterans Administration (VA) coronary patients to determine the probability of coronary surgery prolonging life. The survival data includes operative and late cardiac and noncardiac deaths. Including the MC operative mortality rates but considering late noncardiac deaths withdrawn as alive at the time of death, the MC cumulative 5-year surgical survival rate is 93%. This is identical to predicted 93% 5-year survival rate for any man of 54.5 years, the average age of MC patients living in this geographic locale in 1973. Annual attrition rates, including the noncardiac deaths, are 1.4% for any man 1.5% per year for MC patients, based on MC 5-year survival data. It is probable that coronary surgery prolongs life by sharply reducing late cardiac deaths.

Axillo-axillary bypass for subclavian steal syndrome.

Since 1972, 14 patients with subclavian steal and four with primary vascular insufficiency of the arm have been operated on using the axillo-axillary bypass graft. Two grafts have been replaced, one after nine months for threatened erosion, and the other after three years for thrombosis due to disease progression in the donor artery. The new grafts were patent at three and at 2 1/2 years. One graft was occluded at six months and was not replaced. All other patients under observation in 1978 have grafts patent at one month to 6 1/2 years (average 2.2 years). Life table analysis shows the probability of graft patency (20 grafts) is 76% at three years. In the subclavian steal group steal on the left side predominated 2:1. Cerebral symptoms predominated with arm symptoms less often seen, although six patients had both. Associated vascular disease and hypertension were common. There was no mortality and few complications. Axillo-axillary bypass grafting is considered the operation of choice for patients with subclavian steal syndrome.

Is reperfusion injury from multiple aortic cross-clamping a current myth of cardiac surgery?

Four hundred eighty adult patients undergoing cardiac operations had systemic and topical hypothermic anoxic arrest supplemented with potassium chloride pharmacological cardioplegia in a prospective randomiz ed study. Group 1 (217 patients) had continuous aortic cross-clamping and one single anoxic arrest period during the cardiac portion of the operation, which resulted in a transmural myocardial infarction rate of 8.3%, myocardial "injury" incidence of 12.4%, 4.6% cardiac-related deaths, 11.5% and 24.8% severe and malignant ventricular arrhythmias, 21.7% rate of severe vasopressor usage, a mean group serum glutamic oxaloacetic transaminase (SGOT) of 140 +/- 39 IU, and a mean group lactic dehydrogenase (LDH) of 636 +/- 78.2 IU. Group 2 (263 patients) had intermittent aortic cross-clamping with multiple reperfusion intervals, which resulted in a significantly lower incidence of transmural myocardial infarction at 1.9% (p < 0.01), rate of myocardial injury at 5.66% (p < 0.02), number of cardiac deaths at 0.76% (p < 0.02), 8.7% and 16.0% severe and malignant ventricular arrhythmias (p < 0.01), severe vasopressor utilization rate of 14.3% (p < 0.05), mean group SGOT at 72.0 +/- 3.1 IU (p < 0.01), and mean group LDH at 471.0 +/- 12.3 IU (p < 0.05) than Group 1. These results do not support the contention that intermittent aortic cross-clamping in conjunction with hypothermia and pharmacological cardioplegia leads to increased clinical cardiac damage compared with continuous aortic cross-clamping. The converse is implied, in that the anoxic heart may benefit from the physiological effects of briefly reperfused oxygenated blood.

Management of malignant esophagorespiratory fistula.

Esophagorespiratory communication developed in 46 patients among 570 with esophageal cancer. Therapy was basically palliative and aimed at mechanical interruption of the fistula, restoration of esophageal continuity, and avoidance of external tubes and appliances. Supportive therapy, gastrostomy, tracheostomy, and esophageal exclusion and diversion procedures resulted in little prolongation of life and poor palliation of the patient. Permanent endoesophageal intubation with tubes of the Celestin variety resulted in best palliation with minimal operative risk for most terminal patients. Colon bypass and occasional resection can accomplish the same goal and possibly provide long-term survival in good-risk, young patients with small tumors.

Tandem coarctations of thoracic and abdominal aorta with intervening hypoplastic thoracic aorta: treatment with unilateral axillofemoral graft.

Tandem coarctations of the thoracic and abdominal aorta with an intervening segment of hypoplastic thoracic aorta were discovered unexpectedly in a 14-year-old boy brought to the emergency room for a displaced fracture of the radius. After the fracture healed, the boy's potentially dangerous anomalies were treated successfully with a unilateral axillofemoral prosthetic graft. This has remained patent for 42 months, and the boy has done well.

Reduction of intraoperative myocardial infarction by means of exogenous anaerobic substrate enhancement: prospective randomized study.

In a prospective study, patients who had an ejection fraction of 40% or more and who were undergoing elective coronary artery operation were randomly divided into three groups that differed in the method of anaerobic substrate enhancement during cardiopulmonary bypass. Group 1, the controls (n = 157), received no additional glucose, insulin, and potassium solutions and experienced immediate spontaneous defibrillation (10%), transmural myocardial infarction (10.3%), malignant ventricular arrhythmias (26%), and severe atrial arrhythmias (20%). Group 2 (n = 120) received a bolus of hypertonic glucose, insulin, and potassium in the pump perfusate before aortic cross-clamping. In this group, the rate of spontaneous defibrillation was 41%, of transmural infarction, 8.3%, of malignant ventricular arrhythmias, 31%, and of severe atrial arrhythmias, 19%. Group 3 (n = 114) had the aortic root continuously infused with glucose, insulin, and potassium solution at 4 degrees C during aortic cross-clamping. This group was significantly improved; the rate of spontaneous defibrillation was 60%, there were no transmural myocardial infarctions and the incidence of severe atrial arrhythmias was 6% and that of malignant ventricular arrhythmias, 5%. It is proposed that the superior clinical results in Group 3 resulted from better myocardial preservation achieved by more efficient means of providing continuous anaerobic substrate, coronary washout, and elution of lactic acidosis, uniform global hypothermia, and direct supplemental myocardial potassium in addition to mere cardioplegic effects.

Prognostic value of electroencephalography in cardiac surgery.

One hundred seventeen patients undergoing cardiac operations over a two-year period were studied. Electroencephalograms were recorded preoperatively, in the recovery room (up to 12 hours following operation), 24 hours later, and further as required. Operative and anesthesia data were correlated with EEG findings. All patients had normal EEGs preoperatively. This unusual occurrence may largely reflect the absence of congenital heart disease and the small number of valvular lesions in our patients. Prognosis was not significantly influenced by age. Bypass time appeared directly related to outcome by group but not individually. Hypotension prior to pumping occurred most often and mean blood loss was greatest in the patients who had abnormal EEGs in the recovery room with progressively worsening patterns until death. In the recovery room many patients were awake, while others were either drowsy, lethargic, or asleep. Some were comatose. The level of consciousness was not as prognostic as was the EEG. The pattern of EEGs in the first few postoperative days is more important than any single record by itself. All those who showed progressive deterioration in the first two or three days died shortly thereafter.

Can the frequency of myocardial infarction be reduced during coronary artery operations.

A prospective experiment was carried out in 56 patients undergoing coronary artery revascularization to determine whether those having a glucose-insulin-potassium (GIK) perfusion during the procedure would have fewer myocardial infarctions (MI) compared with patients given a control perfusion of Normosol-R. Six patients (11%) developed an MI, defined as a 24-hour creatine phosphokinase MB isoenzyme value of 100 IU per liter or greater. Four (13%) had control perfusions and 2(8%) had GIK perfusion. One MI in a double-graft recipient who had GIK perfusion occurred because of a technical surgical error; therefore, the corrected MI rate was 13% in control patients compared with 4% for the GIK group. These data, as well as the more frequent spontaneous defibrillation in patients who had GIK perfusion, suggest that GIK was of benefit.

Quadruple coronary artery bypass grafting.

In our last 150 consecutive revascularization operations, 30 patients (20%) have had 4 or more bypass grafts. One patient died after quadruple grafting (mortality, 3%). Twenty-two (75%) of the survivors have been rehabilitated to active work status and 25 (86%) were considered by their cardiologists to have improved function postoperatively by New York Heart Association criteria. Preoperatively 15 patients (50% of the group) had either a markedly diminished ejection fraction (EF) or extreme elevation in left ventricular end-diastolic pressure (LVEDP) or both. Complete revascularization, with resection of ventricular aneurysms when present, can be carried out successfully in a high-risk group of patients. Elevated LVEDP or diminished EF per se is not a valid contraindication to myocardial revascularization.

Platelet dysfunction associated with cardiopulmonary bypass.

The clinical significance and pathogenesis of the platelet dysfunction following cardiopulmonary bypass were studied in conjunction with the degree of functional impairment associated with the use of membrane and bubble oxygenators. Forty consecutive patients had the following tests preoperatively and postoperatively: complete blood count (CBC), platelet count, prothrombin consumption time, bleeding time, prothrombin time, partial thromboplastin time, fibrinogen, euglobulin clot lysis, fibrin degradation products, and platelet aggregation tests. Six patients were given 14C-serotonin tests before and after operation, and preoperative and postoperative electron micrographs were made of the platelets of 3 patients. The amount of blood lost, the blood transfused, and plasma hemoglobin levels were also measured. Abnormal aggregation of platelets was found, with no difference between the membrane and bubble oxygenators. In vitro aggregation tests with protamine sulfate and hemoglobin solutions, as well as the 14C-serotonin studies and electron micrographs, suggest that platelets acquire storage pool deficiency and an abnormal membrane during cardiopulmonary bypass.

Combined carotid endarterectomy and myocardial revascularization.

From February 1971 through December 1987, 95 patients underwent combined carotid endarterectomy and myocardial revascularization. Mortality and postoperative stroke rates were 4 percent and 2 percent, respectively, for the 16-year experience. From 1980 to 1987, when 89 percent of patients had their operation, mortality and stroke rates were 1 percent and 2 percent, respectively. Follow-up carotid duplex scan in 41 patients revealed that 25 percent had more than 50 percent restenosis. Only two in this group were symptomatic. We conclude that the combined approach to concomitant carotid and coronary artery atherosclerosis can be done safely. Continued study with noninvasive testing is important to document restenosis rates.

Effective surgical palliation of giant compressive bullous emphysema (vanishing lung syndrome): long-term follow-up.

Giant compressive bullous emphysema is rare. The three major considerations for operation involve a breathless patient with giant bullae occupying more than one-third of one lung field who has a positive pulmonary arteriogram revealing diminished blood flow to the involved lung. Finally, we think that the survivors in our series, eight long-term postoperative patients alive one year to 14 years, supply gratifying evidence that surgery can provide effective and safe palliation.

Clinical experience with preoperative myocardial nutrition management.

Three hundred and twelve elective adult coronary artery surgery patients were divided into five groups differing as to preoperative glucose or fat loading. The control group (n = 54) had a mean myocardial glycogen level of 880 mg/100 gram heart weight, a 18.5% incidence of serious ventricular arrhythmias, 24.2% dependence on vasopressors, a mean peak postoperative SGOT level of 100 IU, and a 3.7% perioperative transmural myocardial infarction rate. The 10% glucose loading group (n = 67) had elevated myocardial glycogen of 1180 mg/100 gram heart, 14.9% serious ventricular arrhythmias but a lessened dependence on vasopressors (17.9%), a peak post bypass SGOT of 74 IU, and 2.9% transmural infarction rate. A 20% glucose overnight loading group (n = 65) had myocardial glycogen level of 1270 mg/100 gram heart, a 23.0% incidence of serious ventricular arrhythmias, a significant reduction in vasopressor dependence (3.1%), no transmural myocardial infarctions, and peak post bypass SGOT of 53 IU. The intravenous fats (10% Intralipid) group (n = 57) had the highest glycogen level of 1509 mg/100 gram heart, the lowest peak SGOT of 51 IU, no infarctions, a low vasopressor dependence (5.2%), but high rate of serious ventricular arrhythmias (22.8%). The oral fat and 20% glucose loading group (n = 69) had a myocardial glycogen of 1486 mg/100 gram heart, a low vasopressor dependence rate of 4.3%, no infarctions, a peak SGOT of 66 IU, and the lowest serious ventricular arrhythmia rate of 4.3%. These results suggest that it is possible to alter prebypass myocardial substrate levels against the stresses of cardiac surgery with fat and/or glucose loading and that myocardial protection is evident.(ABSTRACT TRUNCATED AT 250 WORDS)