Isolated mitral valve replacement with the Kay-Shiley prosthesis. Long-term follow-up and recommendations.

Eighty patients underwent isolated mitral valve replacement with the Kay-Shiley prosthesis during a 6 year period (September, 1966, in October, 1972) at Walter Reed Army Medical Center. One-hundred percent follow-up has been achieved with this group. Sixty-four percent of this group have experienced one or more thromboembolic episodes (TEEs), for a TEE rate of 28.7 episodes per 1,000 patient months at risk. The 5 year survival rate is 45%. Eleven of 43 (25%) late deaths resulted from TEEs, and 13 of 43 (30%) late deaths were secondary in the hemorrhagic complications of long-term anticoagulant therapy. The dismal TEE rate prompted as to initiate a policy of elective replacement of all Kay-Shiley mitral prostheses. Eighteen of the 26 survivors underwent replacement of the Kay-Shiley mitral prosthesis. The other eight patients either declined reoperation or were not considered suitable candidates. The reoperative mortality rate was 22% (4/18). Fifteen of 18 explained prostheses revealed a yellow disclored, grooved occluder disc with loosely adherent clot. We recommend elective replacement of Kay-Shiley mitral prostheses in all patients in whom the risk of operation is reasonable.

Intrathoracic ganglioneuroblastoma.

Thirty-one patients treated for isolated intrathoracic ganglioneuroblastoma have been evaluated. The surviving patients (27/31) have been followed for periods up to 25 years. The modes of treatment consisted of complete or partial resection of the tumor, radiation therapy, or chemotherapy. Analysis of the data revealed that four patients treated with radiation alone died within 3 months after the start of treatment. Two patients had complete removal of the tumor without adjuvant therapy. Each is free of recurrent disease at 10 and 11 years postoperatively. The other 25 survivors had complete or incomplete surgical resection followed by radiation and/or chemotherapy. All are free of recurrent disease. Of the 25 patients who received postoperative radiation, 11 developed moderate-to-severe skeletal deformity. There appeared to be a correlation between deformity and the dose of radiation. Our current treatment recommendation consists of immediate operative intervention with an attempt at complete removal of the tumor. Patients with incomplete removal of tumor should be treated with radiation (2,000 r). Chemotherapy consisting of methotrexate or a combination of cyclophosphamide (Cytoxan) and vincristine should be reserved for patients with distant metastasis.

Surgical treatment of left main and left main equivalent coronary artery disease.

There is a tendency to equate left main (LM) and left main equivalent (LME) coronary artery disease in terms of the surgical risk and benefit. Eighty-seven patients with LM disease were compared to 78 patients with LME disease as to operative mortality rate and long-term benefits. One hundred percent follow-up was obtained. Although the two groups were similar preoperatively with regard to age, sex, and ventricular function, the operative results in the two groups differed. There was a significantly higher operative mortality rate in the LM group of patients (12.6% versus 2.5%). However, the incidence of graft patency and relief of symptoms was lower in the LME group of patients. The late mortality rate was 4% in both groups. LME disease appears to represent a subgroup of patients with three-vessel disease and cannot be equated with LM disease.

Value of anterior mediastinotomy in bronchogenic carcinoma of the left upper lobe.

Neoplasms of the left upper lobe may spread directly to the anterior mediastinal group of nodes without involving the inferior tracheobronchial, superior tracheobronchial, or paratracheal nodal chain. Routine cervical mediastinoscopy does not sample the anterior mediastinal node group. Parasternal anterior mediastinotomy was performed in 28 patients with left upper lobe carcinoma and normal findings from cervical mediastinoscopy. Despite the normal findings at cervical mediastinoscopy, 10 of the 28 patients were deemed to have inoperable disease because of spread of the neoplasm to the anterior nodal group or because of direct neoplastic involvement of the aorta or main pulmonary artery. All patients in whom results of anterior mediastinotomy were normal had resectable lesions at thoracotomy. Fourteen of the 16 patients who came to thoracotomy had normal hilar nodes. Parasternal anterior mediastinotomy, introduced by Chamberlain, should be performed in addition to standard cervical mediastinoscopy if the nodal drainage of left upper lobe neoplasms is to be more completely evaluated. Combining these two procedures samples all major drainage pathways except the posterior mediastinal nodal chain.

Cardiovascular perfusion: evolution to allied health profession and status 1986.

The occupation of cardiovascular perfusion has evolved from a technical to a professional status during the past 25 years. The national thoracic surgical organizations, The American Association for Thoracic Surgery and the Society of Thoracic Surgeons, have supported this process of development through participation on various boards and committees of the perfusionist organizations. The rapid growth of cardiac surgical services in the past decade produced concern about the availability of perfusionist manpower. This concern was exacerbated by creation of formal processes for the certification of perfusionists and the accreditation of perfusion educational programs. Today, these issues are largely resolved and cardiovascular perfusion is recognized as an allied health profession.

Dipyridamole-aspirin as thromboembolic prophylaxis in patients with aortic valve prosthesis. Prospective study with the Model 2320 Starr-Edwards prosthesis.

In a prospective study, the efficacy of a dipyridamole-aspirin regimen in prevention of thromboembolism was evaluated in 50 patients having isolated aortic valve replacement with the Model 2320 Starr-Edwards prosthesis. These operations were performed between February, 1972, and October, 1974. In 1,380 patient-months of follow-up, there was a 20% incidence of thromboembolism with a rate of 8.7/100 patient-years and a 19% probability of an embolic episode occurring by 3 years. Seven patients had transient episodes, two had permanent neurologic residua, and one patient died. Comparison is made to a similar group of patients having solitary aortic valve replacement but receiving no medication, studied by Starr and associates. There was no statistical difference in the incidence of thromboembolism between the two groups. In November, 1975, all patients were converted to a regimen of warfarin therapy. Since conversion to anticoagulation, there have been two thromboembolic episodes in 2,132 patient-months of follow-up for a rate of 1.1/100 patient-years. We conclude that the use of antiplatelet therapy in the form of dipyridamole-aspirin is inadequate for routine thromboembolic prophylaxis following SE 2320 aortic valve replacement.

Giant coronary pseudoaneurysm. Five-year follow-up after bypass grafting.

A roentgenogram of the shoulder in a 25-year-old man with an athletic injury revealed a large mass along the left heart border. Evaluation with coronary arteriography established the diagnosis of a massive aneurysm of the left anterior descending coronary artery. The aneurysm was excised and a saphenous vein bypass graft was placed into the distal artery. Histologic examination revealed that the excised segment was a false aneurysm. Five years postoperatively, the patient is asymptomatic and the graft remains widely patent.

Drug delivery.

The calculations necessary to allow infusion of a known drug dosage at micrograms per kilogram of body weight per minute are time-consuming and error prone. A simpler method entails multiplication of the patient's weight in kilograms by the factor 15. The resultant figure represents the number of milligrams of drug to be placed in 250 ml of infusate vehicle. The solution, which is delivered through a microdrip chamber (60 gtt per milliliter), will contain 1 microgram per kilogram in each drop. One is thus permitted to define dosage by setting up the solution to have 1 gtt = 1 microgram/kg.

Secundum atrial septal defect and cleft mitral valve.

The association of a secundum atrial septal defect and mitral insufficiency is not uncommon. Five patients with this combination of lesions are presented and the pathological anatomy of the mitral valve is discussed. All 5 patients demonstrated a similar cleft mitral valve; 2 had cleft valves when only mitral valve prolapse was suspected preoperatively. The surgical implication of these lesions is discussed.

A comparison of serum isoenzyme levels of creatine phosphokinase and lactic dehydrogenase in patients undergoing thoracic operations and patients admitted to a coronary care unit.

A prospective study comparing patients undergoing major thoracic surgical procedures with patients admitted to a coronary care unit was conducted. Surgical patients having bronchoscopy and mediastinoscopy (n = 12), anterior thoracotomy (n = 12), and posterolateral thoracotomy (n = 22) were compared with patients in the coronary care unit who had electrocardiographically proved myocardial infarctions (MI) (n = 11) and those with no electrocardiographic abnormalities (n = 12). Sera were studied by spectrophotometric analysis (creatine phosphokinase [CPK] and lactic dehydrogenase [LDH]), agarose gel electrophoresis (CPK and LDH), and antibody inhibition spectrophotometric analysis (CPK). The levels of total CPK did not rise above the upper limits of normal (100 IU/L) in patients who underwent bronchoscopy and mediastinoscopy. Total CPK elevations in patients undergoing thoracotomy (anterior thoracotomy, 428 +/- 62 IU/L [mean +/- standard error of the mean]; posterolateral thoracotomy, 652 +/- 78 IU/L) were not significantly different from those sustaining acute MIs (463 +/- 84 IU/L). Only transient minimal elevations of CPK-MB isoenzyme were noted, however, in the patients having posterolateral thoracotomy (25 +/- 7 IU/L). These were significantly lower (p < 0.001) than the elevations seen in patients sustaining acute MIs (80 +/- 16 IU/L). In none of the surgical patients did LDH1 exceed LDH2 while all of the patients with MIs had such a shift (p < 0.001). The data support the conclusion that the serum isoenzymes of CPK and LDH are capable of confirming the diagnosis of MI in patients recovering from major thoracic surgical procedures.

Thoracic traction for median sternotomy dehiscence.

Standard management of median sternotomy dehiscence sometimes fails to achieve lasting reduction and fixation of the sternal halves. An effective method of external thoracic traction that augments internal fixation of the sternal fracture is presented.

Initial and long-term results in the management of primary chest wall neoplasms.

One hundred ten patients with primary chest wall neoplasms were analyzed for long-term results. The diagnosis of 59 malignant and 51 benign tumors was confirmed by the Armed Forces Institute of Pathology. No deaths were associated with primary definitive therapy. Among the five most frequently encountered malignant tumor types, five-year survivals were obtained in 9 of 17 (53%) patients with fibrosarcoma, 8 of 9 (89%) patients with chondrosarcoma, 2 of 8 (25%) patients with solitary chest wall plasmacytoma (multiple myeloma), 1 of 6 (17%) patients with Ewing's sarcoma, and 2 of 4 (50%) of patients with osteogenic sarcoma. Although the five-year survival appears to indicate therapeutic success in patients with Ewing's sarcoma and osteogenic sarcoma, patients with chondrosarcoma or fibrosarcoma may have a more protracted course, and those with solitary plasmacytoma usually develop multiple myeloma. The findings suggest that radical surgical excision is the treatment of choice for chondrosarcoma; radical surgical excision combined with chemotherapy, for fibrosarcoma and osteogenic sarcoma; surgical excision combined with radiation and chemotherapy, for Ewing's sarcoma; and systemic surveillance and therapy, for pathologically confirmed solitary plasmacytoma.

An analysis of the isoenzymes of creatine phosphokinase and lactic dehydrogenase in the esophagus.

Surgical manipulation of muscular organs can cause alterations of the serum isoenzymes of creatine phosphokinase (CPK) and lactic dehydrogenase (LDH), which are frequently used to confirm the diagnosis of myocardial infarction (MI). Since the content of these enzymes and their isoenzymes has not been established for the esophagus, an experiment was conducted to evaluate and compare the enzymes in postmortem specimens from humans and fresh canine specimens. One gram transmural esophageal sections were taken from specimens having no demonstrable disease. All samples were homogenized individually in Ringer's lactate solution and centrifuged, and the supernatants were analysed for the respective isoenzyme distributions by agarose gel electrophoresis. From the study we drew the following conclusions: (1) all three isoenzymes of CPK (including CPK-MB, the myocardialisoenzyme) are present in the esophagus; (2) LDH, the isoenzyme of LDH most prevalent in myocardium, is the least common of the five isoenzymes of LDH in the esophagus; (3) the dog is an appropriate model for studying changes of these isoenzymes after operation; and (4) any potential confusion in diagnosing postoperative MI due to esophageal CPK-MB in the serum can be resolved, theoretically, by analyzing LDH serum isoenzymes. In myocardial infarction, LDH becomes the predominant isoenzyme, whereas esophageal injury should be associated, theoretically, with a serum LDH isoenzyme pattern in which LDH is the least prevalent isoenzyme.

Vascular trauma secondary to diagnostic and therapeutic procedures: cardiopulmonary bypass and intraaortic balloon assist.

Significant arterial trauma can result from femoral arterial cannulation for cardiopulmonary bypass or intraaortic balloon pumping. Threat of imminent loss of limb or suture line disruption requires prompt surgical intervention. Delayed appearance of claudication, characteristically at 1 to 2 weeks postoperatively, is highly suggestive of iatrogenic iliofemoral injury. Arterial reconstructive surgery was necessary in three of five such patients.

Left atrial myxoma: computed tomography as a diagnostic modality.

The workup of left atrial myxomas has variably ranged from a physical examination, laboratory tests, and echocardiography to the invasive modalities of angiography and cardiac surgery. We propose that computed tomography (CT) be considered a sensitive, noninvasive adjuvant in the diagnosis of these tumors. This report describes successful utilization of CT imaging in one such case of proven left atrial myxoma.