Atrial myxomas: experiences with 35 patients in Hawaii.

BACKGROUND: Thirty-five patients with an intracardiac myxoma underwent excision of the tumor in Hawaii between 1974 and 1993. PATIENTS AND METHODS: There were 28 female and 7 male patients in the group. Their ages ranged from 11 to 79 years (mean 48) with the majority (71%) between 30 and 60 years old. The patients' medical records were reviewed and special attention was paid to clinical presentation, methods of diagnosis, operative findings, and postoperative course. RESULTS: No ethnic predisposition was found. Forty-six percent of the presenting symptoms were cardiac (congestive heart failure 26%, palpitations 14%, and syncope 6%) while arterial embolization accounted for 11%. Diagnosis was made by angiography, echocardiography, or gated cardiac blood pool imaging. All were reliable, but two-dimensional (2-D) echocardiography was used most often, with no false-positive or false-negative results. There were 32 left atrial, 2 right atrial, and 1 biatrial myxomas. Limited septectomy was performed in most cases, but 9 patients (26%) required Dacron patch repair of the atrial septum. There was 1 death from a cerebrovascular accident the day after the removal of a left-sided atrial myxoma. Other patients had few minor postoperative complications. One patient presented with a recurrence 8 years after resection at another institution; no further recurrences were found. CONCLUSIONS: We conclude that due to the non-specific presentation of atrial myxoma, a high index of suspicion is needed. The diagnostic method of choice is 2-D echocardiography. Limited septectomy is a safe procedure, but close follow-up for at least 10 years may be needed to rule out recurrence.

Comparative study of prophylactic antibiotics in cardiac surgery. Clindamycin versus cephalothin.

A randomized, prospective study of the relative effectiveness of clindamycin versus cephalothin was performed in 263 adult patients having cardiac surgery from September, 1977, to August, 1978. There were no statistically significant differences in frequency of postoperative infections in these two antibiotic groups. Wound infection developed in 6.5 percent of the cephalothin group and 3.2 percent of the clindamycin group. Urinary tract infection developed in 5.6 percent of the clindamycin group and 2.1 percent of the cephalothin group. Four bacteremic episodes occurred in the clindamycin-treated patients, and one episode of bacteremia occurred in a cephalothin-treated patient. No cases of endocarditis occurred during the study. Clindamycin deserved consideration as an alternative prophylactic agent to cephalothin for cardiac surgery.

Acute thrombotic obstruction with Björk-Shiley valves: diagnostic and surgical considerations.

Eight patients have had thrombotic obstruction of a prosthetic valve since 1971, six mitral valves and two aortic. All eight patients had a Björk-Shiley valve. During the same period 159 Björk-Shiley valves were placed, 85 in the mitral and 74 in the aortic area. This represents a valve thrombotic occlusive incidence of 4.4 percent in our series, 5.9 percent of mitral and 2.7 percent of aortic prostheses. Among the six patients with mitral prostheses only one survived. The two patients with occluded aortic valves survived. The onset of symptoms was very abrupt in most patients and progressed very rapidly. Acute pulmonary edema was observed in five patients. Anticoagulation was considered inadequate in all patients. Aspirin or dipyridamole was being used in seven patients at the time of thrombosis. The data indicate a high frequency of thrombotic occlusion of Björk-Shiley valves in the absence of full anticoagulation with warfarin derivatives and emphasizes the urgent need for surgery once valve thrombosis is suspected.

Multiple coronary artery bypass using sequential technic.

The relief of symptoms of myocardial ischemia and its lasting effect may be related to completeness of myocardial revascularization. Multiple bypass grafting to arteries with lesser stenosis and to small arteries can be simplified by use of the sequential technic. This can be done with no added risk, but its ultimate effectiveness will have to be determined at a much later date.

Ventricular septal defect and aortic insufficiency. Surgical treatment.

Twenty-five patients with ventricular septal defect (VSD) associated with aortic insufficiency (AI) have been since 1964. Of these patients, one died suddenly without operation; in 2 patients, AI developed in the late postoperative period following VSD closure; and in 3 others, AI developed shortly after VSD closure. The remaining 19 patients are discussed in detail. The VSD was subpulmonic in 13 (68 per cent) and subcristal in 6 (32 per cent). Primary suture of the VSD was undertaken in 13 patients and patch closure in 6. Seven patients had aortic valvuloplasty and 2 had aortic valve replacement. There were no surgical deaths, and the long-term follow-up shows that VSD closure alone has been sufficient to arrest progression of AI in patients with mild insufficiency, particularly in those with subpulmonic VSD. Valvuloplasty, when necessary, was more effective when done at an early age.