Mitral valve replacement: techniques to eliminate myocardial rupture and prevent valvular disruption.

Twenty fresh canine hearts were used to compare the peak left ventricular pressures required to disrupt prosthetic mitral valves sutured in place with horizontal mattress sutures using either subannular or supraannular placed pledgets. Separate groups were developed to determine the effect of leaving the whole mitral valve apparatus or only the posterior leaflet apparatus intact and what effect, if any, each had on the ventricular pressure required to disrupt the implanted prosthetic mitral valve. Group 1 consisted of 10 hearts with the entire mitral apparatus left in place (5 valves implanted with supraannular pledgets and 5 with subannular pledgets). Group 2 consisted of 10 hearts with only the posterior leaflet apparatus left in place (5 valves implanted with supraannular pledgets and 5 with subannular pledgets). A 29-mm Medtronic mitral valve was secured in the mitral position with a fixed number of ten pledgeted sutures in each annulus. The aorta was cannulated and normal saline solution infused into the left ventricle until end-point rupture occurred. The peak pressure and mechanism of any disruption were then noted. No specimen exhibited subannular myocardial rupture or left atrial wall dissection. Similar protection was provided by leaving the posterior leaflet only or the entire mitral valve. In each case peak left ventricular pressure resulted in only paravalvular leaking around the limited number of sutures as the end point. In each of these four groups the peak left ventricular pressures required for end-point rupture were not significantly different.(ABSTRACT TRUNCATED AT 250 WORDS)

A staged expanding pulmonary artery band.

Pulmonary artery banding is indicated in numerous congenital cardiac defects not amenable to a total repair. One complication of pulmonary artery banding, especially in neonates who require early banding, is progressive cyanosis during the rapid growth phase requiring earlier than anticipated total correction, which may produce a less than optimal result. A simple pulmonary artery band that enlarges as the patient grows would avoid this early complication. We report a technique of pulmonary artery banding in an animal model using different absorbable sutures. The band enlarges in a prescribed staged fashion without any further intervention, hopefully allowing growth of neonates and infants with complex congenital heart disease.

Chemoradiation therapy and resection for carcinoma of the esophagus: short-term results.

The purpose of this report is to record the results of a treatment protocol for patients with carcinoma of the esophagus. In May, 1980, we initiated a program of chemoradiation therapy preliminary to resection in patients in whom the protocol was applicable. The chemotherapy consisted of mitomycin-C, 10 mg as a bolus intravenous injection on day 1, and 5-fluorouracil, 1,000 mg per square meter of body surface area in 1,000 ml of 5% glucose solution in distilled water given intravenously on each of days 1 through 4. The radiation therapy consisted of 3,000 rads in three weeks using cobalt 60 or 6 MeV or greater, with ports to cover the tumor and mediastinum. This protocol was given to patients with primary carcinoma of the esophagus whose disease remained or became operable during or following the course of the chemoradiation. Among the patients treated according to the protocol, the operability rate was increased. The resectability rate remained about the same as in our previous experience. The operative mortality was lessened appreciably. The percentage of resected specimens of the esophagus showing residual tumor decreased. However, the absence of any residual tumor in the surgical specimen has not conferred any improved chance of long-term survival to date. There has been a two-year survival of 33% (7/21) among the small group having chemoradiation therapy prior to resection, and this figure is roughly the same as that in our previously reported series of patients treated by preoperative irradiation (4,500 rads in three weeks) and resection without the chemotherapeutic adjunct.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical considerations in tracheal stenosis.

From 1969 to 1990, 43 patients with tracheal stenosis were treated at the University of Mississippi Medical Center. Seventy-four percent of these patients (n = 32) had intrinsic tracheal stenosis, most frequently as a complication of prolonged endotracheal trauma. A total of 41 distinctly separate stenotic segments were identified in the 32 patients. The stenoses were considered moderate or severe in 33 (80%) of the 41 cases and the length of the stenotic segment was greater than 1 cm in 23 (56%) of the cases. An overall 70% success rate was achieved following 93 surgical procedures in this group. The concurrent presence of glottic/subglottic stenosis, multiple segments of stenosis, bilateral vocal cord paralysis, tracheoesophageal fistula, and a tendency to marked hypertrophic scar formation were found to be significant factors in the surgical management of this patient group.

External cardiopulmonary resuscitation augmented by the military antishock trousers.

The external pressure suit (MAST) is beneficial in hypovolemic shock by preventing lower extremity venous pooling. Previous data from this laboratory demonstrated that internal cardiac massage is significantly improved when combined with MAST. This study was designed to see if external massage (EM) could be similarly augmented by this device. Twenty anesthetized pigs underwent left thoracotomy and placement of a left atrial catheter for pressure determination and microsphere injection. A flow probe was placed around the aorta for measurement of cardiac output, axillary artery catheters were placed for blood pressure determination and microsphere sampling, and central venous pressure was monitored. Hemodynamic collection of microsphere injections was performed during resting conditions, during EM alone after electrically induced ventricular fibrillation, and during EM after inflation of the MAST suit. Significant increases in mean arterial pressure, systolic arterial pressure, and diastolic pressure were noted with EM and MAST suit inflation over EM alone. Left atrial pressure doubled during EM and MAST suit inflation. Cardiac output was not augmented by the inflation of the MAST. Myocardial blood flow and brain blood flow increased during EM and MAST, but renal blood flow decreased. These data suggest that unlike internal massage, cardiac output during EM and MAST is not improved by increased venous return and flow during EM may be due to a different mechanism than direct cardiac compression.

Quadricuspid aortic valve with centrally fenestrated leaflets causing aortic insufficiency.

The occurrence of a quadricuspid aortic valve with single, central leaflet fenestrations causing aortic insufficiency has not previously been reported. We recently encountered these features during aortic valve replacement for severe aortic regurgitation in a 20-year-old man who had had a history of aortic insufficiency since age 2 years. The patient's late increase in symptoms was probably due to the fact that 1 of the 4 leaflets was somewhat flail, allowing incomplete coaptation and producing regurgitation over and above that caused by the central fenestrations.

Primary pulmonary hemangiopericytoma in a 3-year-old child.

Hemangiopericytoma is an uncommon and potentially malignant mesenchymal tumor that apparently arises from spindle-shaped pericytes. The tumor usually grows insidiously until considerable size has been reached, at which point symptoms may indicate invasion of the chest wall, mediastinum, or pleura. Because of its malignant potential, hemangiopericytoma must be distinguished from other vascular tumors. While this tumor has been reported in adolescents and adults, it has never before, to our knowledge, been reported in a small child. We present, within the context of a brief review, a case of apparently benign primary pulmonary hemangiopericytoma in a 3-year-old child. Postoperatively, our patient showed no evidence of disease at 9-month follow-up evaluation. However, long-term follow-up is needed in cases of hemangiopericytoma because recurrence over several decades has been shown.

Congestive heart failure with tetralogy of Fallot relieved by an aortopulmonary shunt.

Congestive heart failure occurring in unoperated patients with otherwise uncomplicated tetralogy of Fallot (TF) is rare. We report the case of a boy who was first diagnosed as having TF when he presented at age 3 years with hypoxia and heart failure. Heart failure improved following an aortopulmonary shunt. We attributed his heart failure to cardiomyopathy associated with severe hypoxia. We believe that this report is the first one that attributes heart failure to hypoxia in an unoperated patient with tetralogy of Fallot.

Single- and double-lung transplantation. Problems and possible solutions.

There is a resurgence of interest in single- and double-lung transplantation for end-stage disease. An experience with six double-lung and three single-lung transplants is reported. The lungs were procured from a distance of up to 600 miles and the heart was shared with another team for transplantation in seven of nine instances. The operative mortality rate was 33%. Early transplant infections of donor origin were lethal. Late transplant pneumonitis was well tolerated and recovery was the rule. Three of nine cases had significant tracheal suture line stenosis and were managed conservatively. A technique of bronchial artery implantation using a conduit tailored from donor aorta is described. Transplant rejection was easily diagnosed and treated. Other notable complications included occasional massive pleural fluid loss, temporary space problem, and a delay in the 'resetting' of chemoreceptors resulting in moderate post-transplant hypercarbia accompanied by episodes in which the patient felt hypoxemic despite the maintenance of excellent levels of blood gases. A comprehensive rehabilitation program begun before operation is essential for success.

Aspirated safety pin requiring thoracotomy: report of a case and review.

Foreign body aspirations in children are relatively uncommon occurrences, but they can be a serious events, causing respiratory distress, atelectasis, chronic pulmonary infections, or death. Safety pins are not commonly aspirated objects and account for less than 3% of all foreign bodies found in the tracheobronchial tree. Fewer than 2% of patients require thoracotomy, and most aspirated materials can be removed by bronchoscopy, with low morbidity and mortality. A discussion of airway foreign bodies follows the presentation of a case of an older child who aspirated a safety pin, which required open thoracostomy for removal.

Successful single lung transplantation.

We have presented a successful case of lung transplantation in a man with pulmonary fibrosis. We believe it is the first successful attempt in the United States, following demonstration of its feasibility in Toronto, Canada. Twenty years after the first lung transplantation, several factors have evolved that help to secure a successful outcome, including a strong, dynamic organ procurement system; static, hypothermic lung preservation; omental wrapping of the bronchial anastomosis; improved immunosuppressive agents; and improved postoperative care.