Changes in serum creatine kinase and lactate dehydrogenase caused by acute perioperative myocardial infarction and by transatrial cardiac surgical procedures.

A prospective clinical study was conducted to ascertain if a patient's postoperative elevation in serum creatine kinase MB isoenzyme coupled with determination of the lactate dehydrogenase1/lactate dehydrogenase2 ratio could differentiate whether atrial or ventricular myocardium was the source of these changes. Animal studies have shown that atrial myocardium is as rich a source of creatine kinase MB as is ventricular myocardium. Atrial myocardium has a lactate dehydrogenase1/lactate dehydrogenase2 ratio less than 1.00, whereas in ventricular myocardium the ratio is greater than 1.00. Sixty-four patients were assigned to six groups on the basis of serial electrocardiograms and vectorcardiograms by a cardiologist who was unaware of their clinical courses. The control group (Group 1) consisted of 16 patients admitted to the coronary care unit who had no electrocardiographic changes. Three surgical groups without electrocardiographic or vectorcardiographic evidence of perioperative myocardial infarction were studied: 10 patients undergoing routine coronary artery bypass procedures (Group 2), six adults undergoing repair of secundum atrial septal defect (Group 3), and 13 patients having mitral valve replacement (Group 4). Two groups of surgical patients who had acute perioperative transmural myocardial infarctions confirmed by serial electrocardiograms and vectorcardiograms were studied: 15 patients (Group 5) who had elective coronary artery bypass procedures and four (Group 6) who had mitral valve replacement. This study suggests that serum creatine kinase MB levels in excess of 50 IU/L on the postoperative day 1 and day 2 samples coupled with serum lactate dehydrogenase1/lactate dehydrogenase2 ratios greater than 1.00 on the postoperative day 2 and day 3 samples support the diagnosis of acute myocardial infarction. Patient groups undergoing procedures necessitating atriotomies had average elevations in serum creatine kinase MB and in the lactate dehydrogenase1/lactate dehydrogenase2 ratio, but these were significantly less than those seen when acute perioperative myocardial infarction had occurred.

Pleural chondrosarcoma.

Thoracic extraskeletal chondrosarcomas are uncommon tumors. A case of primary chondrosarcoma of the pleura is presented. Complete surgical resection without adjuvant therapy, even in the presence of pleural seeding, appears to offer a favorable long-term prognosis.

Preoperative vein mapping for coronary artery bypass operations.

High-resolution, real-time ultrasonographic imaging of the greater saphenous veins was performed preoperatively in 100 patients undergoing coronary artery bypass grafting. Vein diameters were measured by ultrasound at four locations in the leg, and the course of the vein in the leg was marked on the overlying skin. Veins removed at operation were measured at the same locations at initial dissection and after vein preparation. The mapped and in situ vein diameters correlated closely, whereas the distended vein diameter was approximately 1.5 mm larger. When greater saphenous veins were absent or diseased, lesser saphenous veins were mapped. No differences in measurements were demonstrated for a variety of patient and operator variables. Major branches or duplications were predicted correctly in 11 patients and venous disease in 13 patients. Mapping influenced the surgeon's choice of the venectomy site in 13 patients. Vein mapping is a simple, accurate, and noninvasive method of imaging the saphenous vein preoperatively. It is useful in demonstrating areas of venous anomalies and disease, and predicts the course of the vein in the leg.

Aortic subannular ventricular aneurysms.

Subannular aneurysms of the left ventricle are rare aneurysms originating adjacent to the aortic or mitral valve. Mitral subannular aneurysms are more common and have been well described. Two cases of aortic subannular aneurysm are reported, and an additional 20 cases were found in the literature. These aneurysms are usually found in young adults who may be seen with congestive heart failure, cardiac murmurs, angina pectoris, myocardial infarction, or even rupture. The aneurysms are often associated with aortic valve anomalies or subaortic stenosis. Diagnosis can be made by echocardiography and cardiac catheterization, and surgical repair is indicated.

Development of circulating antiheart antibodies as a result of coronary bypass surgery.

Antiheart antibodies have been implicated as a marker of postcardiotomy syndrome in patients undergoing coronary artery bypass. To assess the frequency of and contributory factors in the development of antiheart antibodies after coronary bypass procedures, 33 patients were examined for evidence of antiheart antibodies before and for seven days after routine coronary artery bypass operations. Overall titers of antiheart antibodies rose in approximately 66% of the patients. However, this rise was not accompanied by any major clinical symptoms. History of previous myocardial infarction or myocardial injury did not correlate with a higher frequency of development of antibodies. Antiheart antibodies appear to be a common consequence of coronary artery bypass operations and are not routinely associated with the development of postcardiotomy syndrome.

Surgical therapy in the management of coronary anomalies: emphasis on utility of internal mammary artery grafts.

Three patients with an anomalous main coronary artery coursing between the great vessels are presented with a review of the literature. Their surgical treatment by coronary artery bypass grafting with use of the ipsilateral internal mammary artery is described with angiographic follow-up. Young patients with these anomalies, whether they are asymptomatic or have syncope, are at high risk for sudden death. Older patients with angina appear to be adequately risk stratified by thallium stress tests. For patients requiring surgical intervention, aortoplasty and coronary artery bypass grafting have both resulted in relief of symptoms, but the follow-up is limited. We suggest that coronary artery bypass grafting with an ipsilateral internal mammary artery graft to the anomalous vessel is the procedure most likely to relieve ischemia and achieve good long-term results for both symptomatic relief and survival.

Prevention of ventricular fibrillation after myocardial revascularization.

Ventricular fibrillation during reperfusion after aortic cross-clamping for coronary artery bypass grafting may cause subendocardial injury. We investigated the use of lidocaine to prevent ventricular fibrillation during this period. In a blind, prospective, randomized trial, 91 consecutive patients undergoing elective coronary artery bypass graft procedures were given lidocaine (2 mg/kg) or normal saline immediately before removal of the aortic cross-clamp. The groups were similar with respect to demographic, clinical, and intraoperative variables. Myocardial preservation techniques were similar in both groups. Of 47 patients receiving lidocaine, 38 recovered a supraventricular rhythm without ventricular fibrillation, compared with only 5 of 44 patients in the control group (p less than .001). When ventricular fibrillation occurred, patients in the control group required a greater number of direct-current countershocks (2.31 versus 1.86) to convert to sinus rhythm. Transient heart block, requiring temporary pacing, developed in 3 patients in the lidocaine group, compared with 1 patient in the control group. There was no significant difference between the groups in the requirement for perioperative inotropic support (6 of 47 versus 6 of 44) or the number of myocardial infarctions (2 of 47 versus 1 of 44), and there were no deaths in either group. Lidocaine infusion immediately before removal of the aortic cross-clamp significantly reduces the incidence of ventricular fibrillation during the reperfusion period after cardiopulmonary bypass.

Long-term palliation of pulmonary artery sarcoma by radical excision and adjuvant therapy.

The case of an extensive pulmonary artery sarcoma managed by radical excision and homograft reconstruction followed by aggressive chemotherapy and irradiation with prolonged survival is presented. Pulmonary artery sarcomas are reviewed with emphasis on the diagnosis and management of these usually fatal tumors.

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.

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.

Hypertrophic cardiomyopathy: a case of refractory recurrent pulmonary edema.

An unusual case of acute pulmonary edema without associated arrhythmias in a 33-year-old woman is reported. The patient suffered recurrent pulmonary edema refractory to medication and eventual cardiac arrest. Successful emergency myectomy following cardiac arrest allowed the patient to resume an active lifestyle despite significant diastolic abnormality. During an 18-month follow-up the patient suffered one brief episode of pulmonary edema.

Enteroenteric fistula secondary to pancreatic carcinoma: a case report.

Duodenocolic fistula has been reported as the result of a variety of benign and malignant processes, but rarely from a pancreatic carcinoma. Such a case in a young adult is presented. The literature is reviewed; a single duodenocolic and two gastrocolic fistulas secondary to adenocarcinoma of the pancreas have previously been reported.

Presacral teratoma in the adult.

Sacrococcygeal teratomas are unusual tumors in children, and are extremely rare in adults. A review of the literature has revealed 69 reported cases of presacral teratomas in adults, and an additional two cases are presented, one in association with a meningocoele. Surgical excision is the treatment of choice. Malignant changes were noted in 11 per cent of cases.

Phlegmasia cerulea dolens and its association with hypercoagulable states: case reports.

Six patients who developed phlegmasia cerulea dolens are described. All patients had associated hypercoagulable states: heparin-induced thrombocytopenia (2 patients), congenital deficiency of protein C (1 patient), and antithrombin III deficiency (3 patients). Their clinical course and management are discussed. Previous reports have failed to show a definite correlation between phlegmasia cerulea dolens and hypercoagulable states because of an unavailability of appropriate diagnostic techniques. Phlegmasia cerulea dolens is a life- and limb-threatening complication. An appreciation of underlying hypercoagulable states is essential to proper management, prophylaxis, and treatment of this disorder.

Experience with a partnership program for cardiac surgery at a regional military medical center.

A Partnership Program between USAF Medical Center, Wright-Patterson (WPAFB) and Miami Valley Hospital (MVH), Dayton, Ohio, was created through CHAMPUS to provide cardiac surgical services for eligible patients. During the first year of this program, 82 patients underwent 89 percutaneous transluminal coronary angioplasty (PTCA) procedures. Sixty-one patients underwent cardiac surgery at WPAFB, 50 were referred to MVH due to ineligibility or other reasons, and five were referred to other military or civilian hospitals. The program has been successful with low morbidity and mortality (3%). Cost savings for PTCAs was $241,853 and for cardiac surgery was $462,046.