The pathology of surgically excised aortocoronary saphenous vein bypass grafts.

The pathologic features of 60 surgically excised failed aortocoronary saphenous vein bypass grafts from 40 patients were reviewed. In 23 cases the grafts were occluded by intimal fibrosis. In five this was associated with thrombotic occlusion of the remaining lumen. The histologic findings in some of these cases indicated that thrombosis preceded intimal fibrosis. Seventeen patients had graft failure caused by advanced arteriosclerosis. In 13 this was associated with thrombotic occlusion, often due to rupture of atheromatous plaques. The average duration of these grafts was 6--7 years compared to an average duration of 3 years for graft failure caused by occlusive intimal fibrosis, and 7 months for those associated with fibrosis and organizing thrombosis. Vein graft in the arterial circulation are susceptible to atherosclerosis; this becomes a significant problem after approximately 5 years. The pathologic changes closely resemble coronary arteriosclerosis.

Experience with fifty repeat procedures for myocardial revascularization.

Fifty coronary reoperations were performed in 49 patients. The reasons for the operations were occluded or stenotic grafts in 23 patients, an inadequate first operation in 13, progression of coronary atherosclerosis in 3, and combinations of these reasons in 11. Mediastinal adhesions made the operations difficult and produced hazards. Six patients died from the operation. Seven surgical mishaps occurred, including damage to five functioning grafts from the previous operation and laceration of two ventricles. Nine patients had less than complete operations because angiographically demonstrated targets could not be found. Repeat angiography was performed on 9 of the surviving patients. Ten of the 14 new or revised grafts were found to be functioning. Although a repeat operation is more difficult technically and carries additional risks as compared with a first operation, the indications are thought to be the same for both first and secondary revascularization procedures. The increased risks of the repeat operations are compelling arguments to strive for complete revascularization at an initial operation in order to avoid the necessity of the second one.

Long-term survival in bronchogenic carcinoma.

In this report, we shall review the clinical and pathological features of 64 patients who survived 10 years or longer after resection for bronchogenic carcinoma. Most of these patients had either adenocarcinoma or bronchioloalveolar carcinoma. None of them had oat cell carcinoma. In many of the long-term survivors, there were pathological findings generally considered to indicate a poor chance for survival. Thus we believe that curative resection for bronchogenic carcinoma should be attempted whenever feasible to offer the patient every hope of long-term survival.

A method for insertion of a stented xenograft valve in the atrioventricular position.

To facilitate the insertion of prosthetic valves, holders are available which keep the poppet out of the area of suture insertion or keep the open ends of the struts occluded. No such holders are available for use during insertion of xenograft valves, and it seems unlikely that one could be used, for danger of damage to the valve leaflets. To obviate this problem, we have brought the flexible struts together with a suture at the time of insertion. The struts assume their original open position upon cutting the suture.

The superior approach for correction of the supracardiac type of total anomalous pulmonary venous return.

An alternative approach for correction of supracardiac (type I) total anomalous pulmonary venous return is described. A median sternotomy is used. The posterior wall of the left atrium and the common pulmonary venous trunk are exposed through the transverse sinus. A direct anastomosis between these structures, ligation of the systemic-venous connection (vertical vein), and closure of the interatrial septal defect results in a one-stage repair. In our experience with the supracardiac anomaly in 20 patients, we have found that this approach consistently affords better exposure than other techniques currently in use for surgical correction of this anomaly.

How to shorten, lengthen, or untwist saphenous vein grafts.

A simple method is described to correct saphenous vein bypass grafts that inadvertently have been made too long or too short or have become twisted. The essential feature of the technique is the use of a Satinsky vascular clamp to hold the divided ends of the vein and maintain their alignment during the repair. The most accessible portion of the vein is used as the site for the repair, leaving the aortic and coronary artery ends of the graft intact. While we have not had need to use the technique frequently, we have found it to be a simple method and believe it to be useful when such instances arise.

An assessment of Mustard's operation as a palliative procedure for transposition of the great vessels.

Ten patients in whom palliative Mustard operations have been performed for transposition of the great vessels with ventricular septal defect and elevated pulmonary vascular resistance are reported. There has been early or late mortality in this group of patients, and postoperative morbidity has been minimal. Five of them have been recatheterized, and the results indicate substantial improvement in postoperative arterial oxygen saturation with change in pulmonary vascular resistance. The operation is reserved for those patients in whom peripheral desaturation is the major cause of symptomatology. Clinical improvement has been gratifying, and the continued use of the operation in selected patients seen indicated.

Foregut cysts in infants and children. Diagnosis and management.

The charts of 15 patients with foregut cysts were reviewed. The lesions were intrathoracic in 14 patients and in the cervical area in one child. The importance of early diagnosis and surgical management is stressed. In untreated infants with foregut cysts, severe progressive and life-threatening airway obstruction may develop. Since the symptoms of this congenital lesion may simulate other more common diseases of the tracheobronchial tree and esophagus, the physician should become familiar with this disease entity so that proper diagnosis and surgical treatment will not be delayed. The study includes symptomatology, methods of diagnosis, pathologic findings and classification of the cysts.

Ensuring accountability in decision making. A step-by-step approach applies common sense to complex issues.

All institutions must routinely make decisions that may have a profound impact on their organizations and communities. The process used to reach those decisions defines an organization's commitment to its mission, values, and corporate ethics. At Sisters of Mercy Health System in St. Louis (SMHS), a corporate decision-making process was developed over the course of a year and introduced systemwide in 1994. The process establishes a disciplined and accountable technique for evaluating initiatives, discussing options, and arriving at clear, values-based decisions. The process begins with two questions: Is the proposed action compatible with the organization's mission? Will the proposed action advance the mission in any significant manner? Next, a step-by-step approach enables members of the decision-making group to consider the proposed action in light of the SMHS mission and values. Participants explore the implications of the decision from three perspectives: social vision, responsibility, and self-interest. They also consider the potential consequences of the decision on all affected parties, particularly poor and powerless people. SMHS leaders have found the decision-making process brings clarity and comprehension to the task of making decisions.