Survival after embolization of a complete prosthetic aortic valve to the aortic arch.

Partial dehiscence and embolization of poppets, leaflets, and discs are well-known complications of mechanical valve prostheses. Dehiscence with embolization of an entire prosthetic valve is rare. Previous reports of dehiscence and embolization of an entire prosthetic valve are associated with fatality and are the subject of autopsy reports. We report a patient who survived an operation (using cardiopulmonary bypass and total circulatory arrest) to retrieve an embolized prosthetic valve.

The Eloesser flap: past and present.

Leo Eloesser designed a flap to drain acute tuberculous empyema in the 1930s. The original concept and design are no longer efficacious because of the introduction of antibiotics and antituberculous drugs. The flap has been modified in both concept and design over the years and is used today for drainage of chronic empyemas, with or without bronchopleural fistulas. The history of the flap will be discussed.

Hydrothorax, ascites, and right diaphragmatic hernia.

Hydrothorax and/or ascites may be the most striking finding in children with right diaphragmatic hernia. The clinical, radiographic, and pathologic findings of five children with right diaphragmatic defects through which the liver had herniated are described. Three presented with a right hydrothorax, one with a right hydrothorax and ascites, and another with ascites. All four children with large right hydrothoraxes were found to have an incarcerated peritoneal sac filled with fluid in the right side of the chest at surgery or autopsy. Lymphatic congestion and obstruction was the probable cause for the fluid collection, which tended to enlarge with time. This condition may be life threatening, and two of the four patients died soon after birth because of hypoplasia of the lungs. Fetal ultrasonography in both had disclosed right intrathoracic cystic masses, and in one, intrauterine aspiration to decompress the lungs had been attempted. The other two patients are alive and well following surgical repair at 1 week and 7 months of age. Ascites was present in two patients and was believed to be due to hepatic venous obstruction, a mechanism similar to that responsible for the Budd-Chiari syndrome.

Diagnostic open lung biopsy for diffuse pulmonary disease in immunocompromised pediatric patients.

Diagnostic open lung biopsy was performed in 40 pediatric patients with diffuse pulmonary disease and underlying malignancy or immunosuppression. Specific diagnoses on which therapy could be based were made in 32 patients and there was only one false-negative result. Pneumocystis carinii was diagnosed antemortem in 28 patients. Complications of surgery occurred in six patients (15%), but no patients died as a result of the procedure. Open lung biopsy appears to be a safe and effective diagnostic procedure in immunocompromised pediatric patients with diffuse pulmonary disease of uncertain etiology.

Myocardial revascularization in patients 70 years of age and older.

Myocardial revascularization has been carried out by us in 67 patients 70 years of age or older. Advanced coronary artery disease was found at angiography in more than two thirds of the patients. The postoperative morbidity and mortality compare very favorably with those in younger patients. The early and late mortality in the 67 patients was 4.5 percent and 6.0 percent, respectively. Fifty-seven survivors have been followed an average of 21 months; for most patients there has been a pronounced improvement in clinical classification. Properly selected, patients of advanced age can undergo successful revascularization surgical procedures. The adequacy of function of the left ventricle, proper timing of the surgical operation and an aggressive yet realistic approach seem to be major determinants for a good result.

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.

Long-term follow-up of patients with coronary artery bypass grafts.

A follow-up study of 1532 patients who had coronary artery bypass grafts from 1969 through 1974 revealed that the 5-year survival rate was substantially better than that recorded in previously published series of patients with similar disease demonstrated angiographically who did not undergo operation. Within this group of operated patients, those who had complete myocardial revascularization (i.e., three grafts for those with three-vessel disease) experienced a significantly better long-term prognosis than those who had fewer grafts than the number of vessels obstructed. The mortality curve in the completely revascularized patients was very similar to that of the general population of the United States, corrected to correspond to this patient sample in age and sex.

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.

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.

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.

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.

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.