"Tripolar system" for transvenous atrioventricular pacing.

A ventricular inhibited unipolar pacing system in a case of so-called pacemaker syndrome was successfully converted into an atrioventricular sequential system without replacing the ventricular lead.

Aortic valvular insufficiency and postductal aortic coarctation in the adult. Combined surgical management through median sternotomy: a new surgical approach.

A new surgical technique for the relief of aortic coarctation and replacement of the aortic valve has been described. In our patient, aortic valve replacement was combined with a bypass graft from the ascending aorta to the retrocardiac descending thoracic aorta. The clinical findings and the technical details form the basis of this report.

Protection and revascularization of bronchial anastomoses by the intercostal pedicle flap.

We used an improved method for preparation of the intercostal pedicle flap for encircling bronchial anastomoses, and we studied its vascular supply after the operation. The flap was used in 56 patients undergoing various types of sleeve resection and in three patients undergoing single lung transplantation. The technique is simple, fast, and causes neither extra surgical trauma nor complications. It allows satisfactory isolation and sealing of the bronchial anastomosis. Even if complete anastomotic dehiscence occurs (one case), the flap preserves the continuity of the airway, thus avoiding bronchopleural fistulas or other complications. The postoperative arteriographic study of the intercostal artery supplying the flap (performed in 14 patients) demonstrated the full patency of the vessel in all cases. It also showed that a fine vascular network develops around the anastomosis early in the postoperative period.

Computed tomography for the evaluation of intrathoracic invasion by lung cancer.

We conducted computed tomographic examinations of the chest in 171 patients with lung cancer whose disease was subsequently surgically staged; routine mediastinal exploration was undertaken in all patients undergoing thoracotomy (151), and in 20 patients only anterior mediastinotomy or mediastinoscopy was performed. We have considered three groups of patients: In Group I (including all 171 patients) mediastinal lymph nodes were evaluated for metastatic involvement; nodes were considered diseased when greater than 1 cm. Sensitivity, specificity, and accuracy were 95%, 83%, and 89%. Among these 171 patients, 34 (Group II) had a central tumor otherwise considered operable, which was shown on plain roentgenograms to be in contact with the mediastinum; infiltration of hilar and mediastinal vessels and of mediastinal tissues was investigated preoperatively with computed tomography and then ascertained at thoracotomy. Sensitivity, specificity, and accuracy were 68%, 72% and 70%. Twenty-seven patients (Group III) had a peripheral tumor abutting the pleural surface and suspected to invade the parietal pleura and chest wall; patients with evident bone infiltration were excluded. Sensitivity, specificity, and accuracy of computed tomography were 50%, 90%, and 65%.

Temperature-related pacemaker tachycardia.

A case of sudden increase in rate of an implanted ventricular-inhibited pacemaker is reported. Testing of the unit at room temperature revealed the measurements to be entirely within normal limits. Subsequent electrical testing at a temperature of 38 degrees C confirmed the abrupt increase in rate of the unit.

Results of coronary bypass surgery in elderly women.

One hundred two female and 102 male patients all older than 70 years who underwent coronary artery bypass grafting (CABG) between 1978 and 1983 were matched according to age, anginal status, ejection fraction (EF), number of bypass grafts, and year of operation. These 204 patients were characterized by a mean age of 73 years, a mean EF of 64%, a mean of 3.2 bypass grafts per patient, and unstable angina in 82%. Statistical analyses were performed on the following variables in conjunction with patient sex to determine whether the two samples (women and men) can be considered representative of a single patient population: preoperative resting ECG, stress test result, number of diseased vessels, left ventricular end-diastolic pressure, presence of carotid artery disease, use of an internal mammary artery graft, incidence of operative death, perioperative myocardial infarction (MI), hospital complications, late MI, recurrent angina, late death, and cumulative survival. All differences were small and failed to reach statistical significance except that women had a higher incidence of recurrent angina-like chest pain and a higher incidence of ischemic changes in the preoperative ECG and men had a higher incidence of conduction abnormalities. We conclude that in this age group, CABG is equally beneficial to women and men in terms of survival, but may result in less subjective symptomatic benefit in women.

Implantation of permanent transvenous atrial J lead using lateral view fluoroscopy.

Fifty consecutive, tined, atrial J leads were implanted for atrial and atrioventricular sequential pacing using lateral view fluoroscopy for atrial lead manipulation and positioning. The technique is described in detail. It is concluded that lateral view fluoroscopy allows a more expeditious and reliable positioning in the right atrial appendage.

Surgical treatment of 200 consecutive patients with left main coronary artery disease.

Two hundred consecutive patients underwent myocardial revascularization for left main coronary artery disease between January, 1975, and December, 1981. The mean age of this group was 64 +/- 8 years, and 78.5% of the patients were men. The anginal pattern was chronic stable in 6% of the patients and progressive or unstable in the remainder. Resting electrocardiograms showed prior myocardial infarction in 45.5%. Left ventricular end-diastolic pressure was elevated in 145 patients, and ejection fraction was less than 50% in 40 patients. The mean number of bypass grafts per patient was 3.2 +/- 1.4 (standard deviation). Seventeen patients underwent major concomitant cardiovascular procedures. The operative mortality was 3.5%, and the incidence of perioperative infarction was 3%. Factors associated with reduced operative survival were increased age; unstable angina, or acute myocardial infarction, or both; female sex; circumflex-dominant circulation; and major concomitant procedures. Late mortality at a mean follow-up of 33.5 months was 6%, and 91% of the surviving patients assessed their quality of life as "excellent" or "good."

Isolated chronic tricuspid insufficiency due to closed chest trauma: report of a case with long-term follow-up.

A case of isolated chronic tricuspid insufficiency due to closed chest trauma is described in this report. Studies for carcinoid syndrome were negative. At surgery the posterior leaflet of the tricuspid valve appeared to be torn and disrupted. The other leaflets were shortened and atrophic. The results of pre- and postoperative cardiac catheterization with long-term follow-up to the present, and the available literature on this rare entity has been briefly reviewed.

Coronary bypass for left main disease in patients over 70 years of age.

Seventy-one consecutive patients over 70 years of age underwent isolated coronary bypass surgery for left main coronary artery (LMCA) disease between September 1975 and December 1982. All patients had angina; 6% were in NYHA functional class II, 30% class III, and 64% class IV. Intravenous nitroglycerin was required in 25% of patients. Resting electrocardiogram was abnormal in 91% of patients and stress testing performed in 24 patients was positive in all. Degree of left main stenosis graded by diameter was 60 to 70% in 24% of patients and greater than 70% in 76%. In addition to left main stenosis 66% of patients had significant triple vessel disease. Left ventricular end diastolic pressure (LVEDP) was elevated in 69% of patients while ejection fraction (EF) was low only 24%, without correlation between high LVEDP and low EF. Mean number of bypass grafts per patient was 3.4 +/- 0.6. Hospital mortality was 7% and mean post-operative stay was 10.4 +/- 2.0 days. Stepwise multiple regression analysis of 12 variables identified only unstable angina requiring intravenous nitroglycerin as a significant predictor of hospital mortality (p less than 0.01). Follow-up was complete with a late cardiac mortality of 4.5%. Seventy-five percent of surviving patients assessed their quality of life as good at a mean follow-up of 26 months. Coronary bypass for LMCA disease in a non-selected elderly population can be performed with low operative mortality and marked improvement in quality of life.

Advantages of superior approach for mitral valve surgery.

Technical factors in mitral valve surgery (MVS) which may influence neurological complications, trauma to the left atrium and formation of atrial mural thrombi have not previously been described in detail. We have reviewed the records of 146 patients (pts) undergoing MVS through the superior approach between January 1974 and May 1981. The series consisted of 97 females and 49 males with a mean age of 57 +/- 18 years. All but 4 pts were in New York Heart Association functional class III or IV. Twenty-five pts underwent open mitral commissurotomy, 116 had valve replacement and 5 had annuloplasty. Concomitant procedures were coronary bypass in 47, aortic valve replacement in 18 and resection of left ventricular aneurysm in 3. Left atrial thrombi were removed in 21 pts. Thirteen pts (9%) died postoperatively. The causes of death were left ventricular failure in 7, arrhythmia in 4 and atrio-ventricular disruption in 2. Two of these pts also had cerebral dysfunction. Autopsy examination in 8 pts failed to reveal formation of fresh left atrial septal or posterior mural thrombus. Postoperative complications included transient neurologic injury presumed to be due to air embolus in 3 and postoperative bleeding from atrial suture line in one. The mean follow-up for the survivors has been 30 months. There have been 16 (12%) late deaths from 1 to 72 months (mean 15). Autopsy examination of 4 pts and surgical exploration in one other pt which failed to reveal organized left atrial mural thrombus. Only one late death was related to prosthetic thrombosis. This occurred following cessation of anticoagulations.(ABSTRACT TRUNCATED AT 250 WORDS)

Extra-anatomic bypass operation for aorto-iliac disease in poor risk cardio-pulmonary patients.

Three years experience with subcutaneous axillo-femoral and bifemoral bypass surgical procedures has been outlined in patients with poor cardio-pulmonary and other risk related factors. Special emphasis has been made regarding technical consideration; advantages and disadvantages have been discussed. There were 49 limbs at risk in this group of 27 patients requiring axillo-bifemoral in 22, and axillo-unifemoral in 5. Sixty-three percent of patients had associated arteriosclerotic heart disease and 48% had severe emphysema. There were 3 peri-operative deaths for 11% hospital mortality and 3 late deaths (12.5%). Six of the remaining patients for whom long term follow-up is available, acute graft thrombosis occurred in 3 patients salvaged by graft thrombectomy and 4 patients had late thrombosis resulting in 3 permanent graft failures. Two patients required above the knee amputation. Limb salvage and relief of lower extremity ischemic pains has been gratifying. During the limited follow-up period from 1-36 months (Mean 18) there is 87% patency rate for 43 grafts to 43 limbs.

Traumatic sinus node dysfunction.

A 50-year-old man exhibited sinus node dysfunction following non-penetrating chest trauma. Transiently elevated cardiac isoenzymes, together with normal past electrocardiograms, support the contention that the blunt chest trauma was responsible for the sinus node dysfunction. This case suggests that this condition may occur more frequently than expected and remain unrecognized. Temporary and subsequent permanent pacing may be necessary. Also emphasized is the potential for liability issues.

Right atrial myxoma with atrial septal defect: a case report and review of the literature.

We report the case of a 63-year-old woman presenting with progressive dyspnea of insidious onset culminating in severe central cyanosis. Conventional studies including M-mode echocardiography did not point to the diagnosis. At cardiac catheterization a large right atrial myxoma producing partial dynamic tricuspid obstruction was discovered along with an atrial septal defect with a right to left shunt. After successful surgical excision of the tumor and repair of the atrial septal defect, the patient has been totally relieved of her presenting symptoms.

The role of intra-aortic balloon pump in the management of patients with main left coronary artery disease.

Seventy-five patients with greater than or equal to 70% stenosis of the left main coronary artery (LMCA) were treated surgically between January 1974 and February 1980. The group consisted of 57 men and 18 women with a mean age of 62.8 years. All patients were symptomatic with angina pectoris, and 64 (85%) had unstable angina. Twenty-nine patients (38.6%) had electrocardiographic evidence (ECG) of old myocardial infarction (MI) and only six (8%) had a normal resting ECG. Preoperative exercise testing was done in 22 of the 75 patients. The stress test was positive in all patients, 17 (77%) of whom had greater than 2 mm ST depression; 90.6% (68/75) had significant right coronary artery disease. The intra-aortic balloon pump (IABP) was inserted preoperatively in only four patients (5%) and was required in two additional patients postoperatively. The IABP was inserted preoperatively in four patients because of medically refractory angina and not on the basis of coronary anatomy alone. An average of three grafts per patient were inserted. There were three (4%) postoperative myocardial infarctions and two (2.6%) deaths. During the follow-up period, which comprised 105 patient-years, there was one myocardial infarction and one death. These data indicate that successful surgical treatment of left main coronary artery disease can be achieved with low mortality and that routine preoperative insertion of IABP is unnecessary.