Early pleural decortication for thoracic empyema in immunosuppressed patients.

Patients with empyema and impaired immune response often remain in a toxic condition after tube thoracostomy because the infection is not localized and walled off satisfactorily. Consequently, the reported mortality rate is extremely high. Despite the expectation of a high mortality rate from thoracotomy and débridement in this category of critically ill patients, we were forced to perform pleural decortication in eight patients after lesser procedures had failed. They were immunodeficient because of (1) high-dose steroids (HDS) for sagittal sinus thrombosis, (2) HDS for systemic lupus erythematosus, (3) HDS for chronic myelogenous leukemia and myelofibrosis, (4) HDS for multiple myeloma, (5) hemolytic anemia with pulmonary infiltrates, (6) chemotherapy for Hodgkin's disease, (7) diabetes mellitus with Kimmelstiel-Wilson disease, and (8) diabetes mellitus with chronic glomerulonephritis. Six of the eight patients survived and were discharged with completely healed incisions 3 to 6 weeks after operation. This compares well with the survival rates reported by others. Although risky, the over-all survival rate may be better with thoracotomy and decortication than with prolonged tube drainage and open drainage in immunodeficient patients with empyema, and the period of morbidity is shortened considerably.

The significance of bundle branch block in the immediate postoperative electrocardiograms of patients undergoing coronary artery bypass.

Three hundred sixteen consecutive patients undergoing coronary artery bypass were studied for postoperative electrocardiographic conduction disturbances. Fifty-five of these 316 patients had postoperative bundle branch block (Group 1). This group had a higher incidence of left main coronary stenosis, together with previous inferior myocardial infarction, than patients without postoperative conduction disturbances (Group 2). Perioperative myocardial infarction, low cardiac output, and death were significantly more common in Group 1 than in Group 2: 7.3% versus 1.9% for perioperative myocardial infarction, 16.4% versus 2.7% for low cardiac output, and 5.5% versus 0.8% for death. Analysis of the type of conduction disturbances indicates that the presence of a new complete left bundle branch block postoperatively in a patient undergoing coronary artery bypass is a sign of intraoperative myocardial damage. This damage is potentially lethal, especially in a patient with left main coronary stenosis and previous inferior myocardial infarction.

Myocardial protection with cold, ischemic, potassium-induced cardioplegia.

A total of 204 patients, ages 3 months to 84 years, underwent open-heart surgery with the aid of cardiopulmonary bypass with moderate hypothermia. For protection of the myocardium, cardioplegia was induced by washing out the coronary arteries with an iced, buffered, isoosmolar, potassium-based infusate. After aortic cross-clamping, the aortic root or individual coronary arteries were perfused with 500 to 2,000 c.c. of an aqueous solution (at zero to 4 degrees C.) containing 20 mEq. of potassium. Periods of ischemic arrest as long as 208 minutes have been well tolerated, with only two of the eleven hospital deaths considered heart related. Defibrillation occurred spontaneously in 41 per cent and after one shock in 47 per cent of patient, without apparent correlation between duration of ischemia and restoration of effective rhythm.

Surgical management of severe aortic coarctation and interrupted aortic arch in neonates.

Forty-four infants, 2 to 90 days of age, with severe obstructive lesions of the aortic arch, underwent emergency surgical correction between Jan. 1, 1966, and April 1, 1975. The typical clinical presentation was severe congestive heart failure and acidemia. Resection of an aortic coarctation with end-to-end anastomosis was performed in 31 patients. Eight (26 per cent) died after the operation. Since 1969, the mortality rate has been reduced to 14 per cent (3 of 22 patients) even though the incidence of major associated cardiac lesions has remained essentially constant (56 per cent from 1966 through 1969, 64 per cent from 1970 through March, 1975). This suggests that the higher survival rate has resulted from improved surgical techniques and postoperative care. The mortality rate in the infants operated upon during the second and third months of life was twice as high as that in those operated upon before the age of 1 month. Eight patients with Type A interrupted aortic arch were operated upon and 5 survived. Five patients with Type B aortic arch were operated upon and 3 survived.

Is mediastinoscopy necessary in the evaluation of lung cancer?

The records of 96 consecutive patients who underwent mediastinoscopy and were ultimately shown to have bronchogenic carcinoma were reviewed. Indirect tests for mediastinal tumor metastases in these patients included bronchoscopy and chest roentgenograms in all 96, mediastinal laminagrams in 65, esophagograms in 27, carinal biopsy in 23, bronchograms in 5, pulmonary angiograms in 5, azygograms in 2, and aortograms in 2 patients. Of the 43 patients in this series in whom all indirect tests revealed no metastases, mediastinoscopy showed nodal involvement in 11 (28%), who were thus spared unnecessary thoracotomy. On the other hand, if negative mediastinoscopy had not cast doubt on the validity of indirect tests that seemed to show metastases, an operation might actuallly have been denied to 14 patients who were ultimately proved to have anatomically resectable disease.

Preparation of oxygenated cold crystalloid cardioplegic solution.

The value of oxygenated, aqueous, cold cardioplegic solutions is being evaluated at several centers. The theoretical advantages of such a solution are counterbalanced in part by the complexity and expense of the preparation and delivery systems that have been used. A simple method is described that effectively achieves satisfactory levels of oxygenation of the cardioplegic solution within its original vinyl container.

Angioplastic repair of a ruptured pulmonary artery aneurysm.

A 28-year-old woman had a ruptured solitary pulmonary arterial aneurysm which was successfully treated by pericardial patch graft. The etiology of the aneurysm could not be determined although the patient had had several episodes of blunt chest trauma in the past. Unusual aspects of this case include: location of the aneurysm in the intermediate portion of the left pulmonary artery within the major intralobar fissure, intrapleural rupture, preoperative diagnosis by pulmonary angiography, and an incidentally discovered histopathological abnormality of the aneurysm itself for which no satisfactory explanation has been found.

Occluder disruption of Wada-Cutter valve prosthesis.

Total detachment and embolization of the hinged, tilting occluder of the Wada-Cutter prosthetic heart valve was the proved cause of death in 2 of 25 patients who had these devices implanted at the University of California, San Francisco, Medical Center in 1969-70. In addition, there were 8 late deaths without postmortem examination, 2 of which were sudden and 4 of which followed rapidly progressive congestive heart failure over a period of hours to days. Prosthetic malfunction appears to be a possible mechanism of death in the majority of these patients. The 2 additional late deaths were unrelated to valve malfunction. Regurgitant murmurs have been identified during follow-up examination in 17 patients. Two patients had prosthetic replacement for hemodynamically significant leaks through the valve mechanism and were found to have no perivalvular leak. Six additional patients had prophylactic replacement of the Wada-Cutter valve. Measurements on 7 available occluders that were removed showed variable degrees of material movement at the hinge. This experience has caused us to recommend elective replacement of remaining Wada-Cutter valves.

Modified pericardial closure to protect cardiovascular structures during sternal reentry.

A technique is described for covering the anterior surface of the heart and bypass grafts with autologous pericardium after myocardial revascularization. A trapezoidal flap is created that incorporates bilateral relaxing incisions to avoid distortion of grafts or increased risk of pericardial tamponade.

Infant coarctation: a spectrum in clinical presentation and treatment.

Between 1975 and 1985, 125 infants 2 to 365 days old (majority, 30 days old or less) with coarctation of the aorta underwent surgical repair. Forty-seven patients (38%) had severe congestive heart failure (CHF), metabolic acidosis, and poor systemic perfusion. The predominant operative technique was synthetic patch aortoplasty (100 patients); the remaining 25 had an end-to-end anastomosis. There were no operative deaths. Perioperative complications were minimized with the synthetic patch technique (less than 15%). For patients surviving at least 3 months after repair, the arm-leg systolic blood pressure gradient was relieved in 82% (71/87) of the patients having patch aortoplasty versus 65% (15/23) of the patients with end-to-end anastomosis. Although the rate of reoperation between the two groups was similar (patch, 5 [6%]; end-to-end, 3 [13%], two of the reoperations in the patch group were for preexisting hypoplastic transverse aortic arch. Late deaths (20 patients, 16%) were due to other major associated cardiac anomalies. Patch aneurysms have not occurred. Expedient use of synthetic patch aortoplasty has decreased perioperative complications, relieved coarctation gradients for CHF, increased early survival even in the presence of complex or associated cardiac anomalies, and has an acceptable rate of recurrent coarctation (6 to 13%).

Reconstructive surgery for obstructing lesions of the intrathoracic trachea in infants and small children.

This is a report of ten infants and small children with congenital obstructive lesions of the distal trachea and main bronchi. Four were successfully resected. One with a distal segment stenosis required tracheal resection at age 6 wk, another with stenosis of the distal half of the trachea at age 18 mo, and 2 (1 with distal stenosis and 1 with tracheal hamartoma) at age 4 yr. All 4 are presently free of symptoms and their anastomoses have grown without stricture. A child with coil-spring mucosal stenosis of the left main bronchus developed an excellent airway following bronchoscopic removal of the folds, and a baby with tracheomalacia was successfully treated with a rib splint on a segment of distal tracheomalacia, but she died later of associated cyanotic congenital heart disease. Four babies died with airway obstruction in the newborn period. Two with critical distal stenoses died before tracheal reconstruction could be performed. Two died following emergency resections in which all of the congenital stenosis could not be removed. In both, stenotic trachea remained despite operation. All of these infants had complete cartilage rings the entire length of the trachea. Congenital lesions of the distal trachea may become suddenly life-threatening at birth or during the onset of a respiratory infection. An abrupt or insidious onset of airway symptoms requires an expeditious diagnostic evaluation to define the tracheobronchial anatomy, and the operating team has to be prepared for emergency tracheal reconstruction.

Surgical treatment of post-infarction ventricular septal defect without concomitant myocardial revascularization.

Twenty one patients suffering from rupture of the ventricular septum (RVS) following acute myocardial infarction were operated upon between 1982-1985. Eighteen patients were operated upon urgently within 9.3 +/- 2.1 hours following diagnosis of RVS. In all, RVS occurred during the first infarction. None had concomitant myocardial revascularization. There were twelve operative survivors for an operative mortality of 42.5%. Two patients died 6 and 9 months postoperatively. All survivors are in functional class I, during a follow-up period of 14 to 56 months. The need for urgent repair of RVS is stressed and the value of concomitant coronary artery bypass is discussed.

Regulation of respiration by bronchopulmonary receptors in conscious dogs.

In awake dogs, the Hering-Breuer inflation reflex (HBIR) was present but weaker than during anaesthesia. Auditory or visual distraction, increased body temperature, and exercise decreased or abolished HBIR. Bilateral complete vagal blockade resulted in slow deep breathing, but arterial PCO2, and apnoeic threshold PCO2, were unafected. Vagal blockade decreased the response of frequency of respiration during hypoxemia and hypercapnia, but did not affect the response to increasing body temperature or to exercise. Progressive cooling of the exteriorized vagal loops from 16 to 9 degrees Celsius resulted in progressive abolition of HBIR, but the respiratory response to inhaled histamine was unaffected. There was a decrease in the expiratory phase of respiration and in tidal volume; the dogs hyperventilated at rest and had an increased respiratory response to inhaled CO2. Further cooling of the vagal loops sufficient to abolish the respiratory response to inhaled histamine resulted in the slow, deep breathing pattern and impaired respiratory frequency response to inhaled CO2 typical of the completely vagotomized animal.