Pulmonary blastoma.

Two cases of pulmonary blastoma are reported. One occurred in a 29-year-old man 31 months after a cyst had been excised from the same pericardial-pleural area. The cyst appeared to be of mesothelial origin and, although supported by a cellular stroma, was originally considered to be benign. The morphologic features, location, and possible relationship to a mesothelial lesion suggest an embryonal-mesothelial origin of the tumor. The patient died of recurrent and metastatic disease 9 years after the first resection. The second case is that of a now 74-year-old woman who, over a period of 19 years, has had six separate small peripheral lung tumors excised. They originally resembled fibrous hamartomas but included embryonal-type immature areas and became increasingly more cellular and sarcomatous. The fine structure of the recurrent tumors is that of primitive stroma with few fibrils but no other differentiating features.

The effectiveness of topical cardiac hypothermia.

The effectiveness of cooling the subendocardial myocardium by five different methods was evaluated in a group of 100 patients. The most effective and consistent method to cool the heart was by total body hypothermia with the heat exchanger in the cardiopulmonary bypass system. Myocardial temperature became equal to vena caval blood temperature after only a one minute lag. The least effective methods of myocardial cooling were those in which a bath of chilled fluid enveloped the outside surface of the heart, with and without aortic cross-clamping. The drop in ventricular septal temperature was so small that topical hypothermia, by itself, may be worthless. Two methods in wich chilled fluid was perfused through the coronary system produced a significant lowering of myocardial temperature. One of these methods employs coronary perfusion with a cold cardioplegic solution in addition to total body hypothermia. It is our current choice for myocardial protection during cross-clamping of the ascending aorta.

Thermodilution cardiac output studies as a cause of prosthetic valve bacterial endocarditis.

The injectate used for thermodilution cardiac output determinations is a potential source for direct bloodstream contamination, resulting in bacterial endocarditis after cardiac operations. An experiment simulating three techniques for obtaining injectate samples showed one of them to be clearly unacceptable.

Anomalous left coronary artery from the pulmonary artery. Significance of intercoronary collaterals.

Seventeen patients with an anomalous left coronary artery from the pulmonary trunk underwent surgical treatment and were evaluated, with a mean follow-up of 9.5 years. Analysis has included clinical symptoms cardiac laboratory tests, angiographic grading of intercoronary collaterals, echocardiographic and angiographic measurement of left ventricular function, surgical methods, and the postoperative outcome. Ten patients (59%) survived, and there were seven early deaths. The only significant variable relating to survival was the extent of preoperative intercoronary connections. In survivors, the postoperative left ventricular ejection fraction increased from 45% +/- 25% to 64% +/- 14% (p < 0.01). Nine of ten survivors are free of symptoms and have normal left ventricular function. Nevertheless, half of all created anastomoses were occluded within 2 years of the operation. We speculate that even if temporarily constructed, a dual coronary supply allows for left ventricular recovery and normalization of function.

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.

Suture technique in preventing dehiscence of prosthetic mitral valves.

To evaluate suture techniques for mitral valve replacement, 60 fresh porcine hearts were used to determine suture holding strength. Using four techniques (simple interrupted, figure-of-eight, and horizontal without and with pledgets), the anterior leaflet, the posterior leaflet, and the commissures were sutured. The free ends of the sutures were then attached to a force transducer, and tension was increased until disruption occurred. In the anterior leaflet, horizontal mattress sutures disrupted with significantly less force than the other techniques. Pledgets increased the holding strength of mattress sutures, but figure-of-eight and simple interrupted sutures had greater holding strength than sutures with pledgets, suggesting that the direction of the suture vs that of tissue fibers is critical. Histologic studies confirmed this point. The posterior leaflet exhibited less holding strength than the anterior leaflet for all suture techniques but did not demonstrate a superiority for any specific technique. The posterior leaflet is the problem area for suture disruption from the mitral anulus. We secure mitral prostheses with horizontal mattress sutures with pledgets around the entire anulus, placing them from the atrial side.

Massive venous air embolism during cardiopulmonary bypass.

A massive bolus of oxygen was forced into the right atrium and venous system of a patient during cardiopulmonary bypass using a Bentley BOS-10 oxygenator. The unique design of the oxygenator canister provides an explanation for the event. Methods are outlined to avoid this type of venous embolism.

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.

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.

Current techniques for chest wall reconstruction: expanded possibilities for treatment.

Myocutaneous flaps and prosthetic materials have greatly facilitated reconstruction after massive chest wall resection. This series includes 112 such procedures. Latissimus dorsi, rectus abdominis, omental, pectoralis major, and contralateral breast flaps were used in 80 patients. Early in the series, 3 flaps were lost because of technical problems. Minor areas of incomplete healing that resolved completely with local wound care occurred in 16 of 80 flaps. Skeletal reconstruction was performed in 82 patients without complication. Marlex mesh was used for flat surfaces, and Marlex mesh with methyl methacrylate was used for the sternum and the curved surface of the lateral chest wall. These results have allowed an expansion of the indications for chest wall resection to include the curative treatment of primary chest wall tumors and palliative treatment for breast cancer patients with osteoradionecrosis, local recurrence (in select patients), chest wall infection, and tumors metastatic to the chest wall.

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.

Options in the management of perforations of the esophagus.

A study of 90 cases of esophageal perforation in the antibiotic era emphasizes individualized treatment and options of therapy based on a fundamental understanding of modifying pathophysiologic factors. If the patient is seen during the first 24 hours, surgical repair and irrigating tube drainage continue to be the treatment of choice in the thoracic and abdominal regions, with certain exceptions. The exceptions include small perforations proved by a thin media esophagram or esophagoscopy without pleural involvement or constitutional symptoms. Such patients may be treated nonoperatively, with gastric drainage, antibiotics, and parenteral alimentation. However, for large perforations with extensive contamination of the mediastinum and pleura, an esophageal exclusion operation may be life saving. In the cervical region, irrigating tube drainage may be just as effectual as repair and drainage. In patients seen after 24 hours, size of the perforation and the amount of mediastinopleural infection, rather than the time that has elapsed, dictate optimal treatment.

Management of injuries of the thoracic and abdominal aorta.

Thirty-five patients had surgery for injuries of the aorta at the Los Angeles County-USC Medical Center over a 4 1/2 year period. There were 27 survivors. The principles of management were to operate without delay if there was evidence of continued bleeding after initial fluid replacement as occurred in 11 patients. For the 24 patients who became stable after initial resuscitation, a more deliberate plan of management was used. Blood pressure was carefully monitored and controlled to avoid hypertension. Priorities for associated injuries were established and in several cases, they took treatment precedence over the aortic injury. Delay was sometimes necessary to utilize the more experienced personnel. In no instance did a stabilized patient hemorrhage during the delay. The most common injury seen was a blunt disruption of the proximal descending aorta. The details of the operative technique for this injury have been reported herein, along with a justification for not using either pump bypass or shunt to perfuse the distal aorta during the period of aortic cross-clamping.