Primary cardiac valve tumors.

Cardiac valve tumors are rare, but may have significant clinical manifestations. We report three cases of mitral valve tumor successfully treated by surgical excision. Two out of three patients presented with neurologic symptoms, and by utilizing echocardiography the valvular lesions were discovered. Surgical removal with preservation of normal valve tissue and function was accomplished without difficulty in all cases. A literature review was performed which comprises case reports of one hundred and twenty-eight patients. Most were asymptomatic, but when symptoms did occur, they could be disabling, such as stroke, myocardial infarction and sudden death. Transthoracic and transesophageal echocardiography has greatly enhanced the ability to make this diagnosis in a timely fashion. Papillary fibroelastoma is by far the most common lesion and is amenable to simple surgical excision with minimal morbidity and mortality. Recurrence has not been reported.

Pancreatic complications following cardiopulmonary bypass. Factors influencing mortality.

Pancreatic complications following cardiopulmonary bypass are infrequent but are associated with high mortality. All cases of pancreatic complications following cardiopulmonary bypass from 1972 to 1987 at a single institution were retrospectively reviewed. Of 5621 patients who underwent cardiopulmonary bypass, 25 (0.44%) sustained pancreatic complications. There were 15 cases of acute pancreatitis and 10 cases of pancreatic necrosis, with 11 deaths in the group reviewed, a mortality rate of 44%. Factors that were correlated with mortality associated with pancreatic complications in this study include preoperative hypotension, preoperative use of inotropic agents, and renal failure (preoperative and postoperative). Factors that have been previously associated with mortality from pancreatic complications in other studies, such as fluid sequestration, respiratory failure, sepsis, tachycardia, hypocalcemia, age greater than 55 years, and abnormal laboratory findings, were not found to be significantly associated with mortality in this study. Of the five patients for whom complete data were available, not one patient received greater than 800 mg of calcium per square meter of body surface area in the perioperative period. While the exact mechanism of pancreatic injury remains unclear, based on experimental studies and clinical correlation, it is likely that pancreatic ischemia remains a significant contributing factor. We conclude that no factor specifically associated with cardiopulmonary bypass was correlated significantly with mortality.

Rapid bedside method to assess changes in postoperative fluid status with bioelectrical impedance analysis.

BACKGROUND: Estimates of daily postoperative fluid balance usually rely on properly recorded inputs, outputs, and daily weights or clinical signs. These may be imprecise (when poorly done) and are often considered tedious to perform. METHODS: We used bioelectric impedance analysis (BIA) to assess changes in body water shifts in cardiac patients after surgery. Nine consecutively admitted patients undergoing coronary artery bypass (seven men and two women; age range, 43 to 67 years) were studied. Body weight, fluid intake and output, and BIA variables (resistance and reactance) were measured daily. Relationships between body weight and changes in resistance and reactance and net change in fluid balance (in liters per day) were evaluated statistically by regression analysis. RESULTS: Mean body weights changed significantly, reflecting early operative fluid accumulation and later postoperative diuresis; net fluid balance correlated poorly (r = 0.48; p less than 0.05) with body weight, whereas both resistance (r = -0.82; p less than 0.001) and reactance (r = -0.92; p less than 0.0001) correlated highly with net fluid balance. CONCLUSIONS: BIA is useful as an accurate, rapid bedside method for assessing changes in hydration status sequentially after surgery in cardiac patients with complicated fluid shifts.

Bacteremia and sternal infection after coronary artery bypass grafting.

Sternal wound infection remains a source of substantial morbidity and mortality after coronary artery bypass grafting. We noted an association between bacteremias and sternal wound complications in these patients. A review of 835 consecutive coronary bypass patients showed a 3.2% incidence of bacteremia and a 1.9% incidence of deep and superficial sternal wound infection. The sternal wound was the most common source of bacteremia, accounting for 59% of the infections. Coagulase-negative Staphylococcus was responsible for one half of the sternal wound infections. Often, a positive blood culture was the first manifestation of wound infection, occurring before local signs were manifest. We recommend multiple blood cultures in postoperative coronary bypass patients with pronounced fever. If no source of infection can be identified, sternal wound aspirate may be revealing. Appropriate early wound management can then be carried out, maximizing chances for good recovery.

Blunt injuries to the aortic arch vessels.

Thirty patients with 33 vascular injuries from blunt trauma to the brachiocephalic branches of the aortic arch are reported. To our knowledge, this is the largest series reported to date of blunt injuries to these vessels. Mechanisms of injury included deceleration, traction, and crush. Half of the injured vessels were the innominate artery, and a quarter each were the common carotid and subclavian arteries. Common associated injuries were head injuries, hemopneumothorax, lung contusion, long bone fractures, and brachioplexus injuries. Widened mediastinum and extrapleural hematoma were common radiographic findings, and aortic rupture was frequently suspected. Angiography was performed in all patients to identify precisely the nature and site of the injury. Surgical approaches varied with the anatomical site of the injury and required consideration of vascular control in chest, neck, and upper extremity. Twenty-seven patients are alive 6 months to 10 years after injury. Eighteen of 20 vascular reconstructions were patent at follow-up. No patient with brachioplexus injury had return of neurological function.

Radiographic appearances of the St. Jude Medical Valve.

The St. Jude Medical Valve (SJMV), one of the more popular prosthetic cardiac valves in use today, has been described as poorly visualized on plain radiographs, being visible only at fluoroscopy. The chest radiographs of 76 patients (85 valves) in whom the SJMV had been implanted were reviewed in order to assess the visibility and appearances of the SJMV. We found that the SJMV was visible postoperatively in 70 of the 76 patients (92%) on either frontal or lateral chest radiographs or both. Knowing the various normal appearances of the SJMV described here and the anatomic locations of the heart valves, radiologists should be able to visualize and identify this prosthetic valve on chest radiographs in the majority of patients.

Composite graft replacement of the ascending aorta and aortic valve. Late follow-up with intra-arterial digital subtraction angiography.

Between 1979 and 1986, 30 patients underwent replacement of the aortic valve and ascending aorta by a composite graft, with aortic wrapping of the graft. Thirteen patients had annuloaortic ectasia; six had DeBakey type I dissection (five acute, one chronic); three had DeBakey type II dissection (one acute, two chronic); three had left ventricular-aortic discontinuity caused by prosthetic valve endocarditis; three had sinus of Valsalva aneurysms after previous aortic valve procedures; and two had atherosclerotic aneurysms. Three patients died (10%). The mean duration of follow-up was 54 months. Fifteen patients consented to be restudied by intra-arterial digital subtraction angiography; studies were performed 6 to 58 months (mean 25 months) after composite graft replacement. Two patients had pseudoaneurysms at the right coronary anastomosis, which were repaired successfully. One patient showed persistent dissection beyond the distal aortic anastomosis; no reoperation has been done. One patient had pulmonary edema. Emergency study and reoperation showed disruption of the proximal aortic anastomosis and right coronary anastomosis. Anastomotic dehiscence after composite graft replacement is potentially lethal. Follow-up by means of intra-arterial digital subtraction angiography is simple and highly accurate. We suggest that dehiscences may occur early in the postoperative period and that restudy may be appropriate within a few months after operation.

Pulmonary hypertension in isolated aortic stenosis. Hemodynamic correlations and follow-up.

The clinical, hemodynamic, and angiographic data on 92 patients with severe isolated aortic stenosis were reviewed to determine the incidence and mechanism of pulmonary hypertension. The status of each of these patients was determined 1 to 8 years after diagnosis by cardiac catheterization. Patients were divided into three groups on the basis of the pulmonary artery systolic pressure: group 1 (less than or equal to 30 mm Hg), 46 patients; Group 2 (31 to 50 mm Hg), 31 patients; and Group 3 (greater than 50 mm Hg), 15 patients. The prevalence of pulmonary hypertension was 50% (46/92) and that of severe pulmonary hypertension, 16% (15/92). There was no significant difference in age, aortic valve gradient, or valve area among the three groups. There was a significant positive correlation in left ventricular end-diastolic pressure (group 1, 15.5 +/- 7.2 mm Hg; group 2, 23.3 +/- 8.1 mm Hg; and group 3, 29.5 +/- 5.8 mm Hg; R = 0.56, p less than 0.01). There was also a significant negative correlation in left ventricular ejection fraction (group 1, 67.5% +/- 14%; group 2, 62.3% +/- 13.8%; and group 3 49.9% +/- 18.3%; R = 0.43, p less than 0.01). Of the 92 patients, 85 had aortic valve replacement with four (4.7%) hospital deaths. Follow-up showed excellent symptomatic relief in all three groups. Thirteen of the 15 patients in group 3, with severe pulmonary hypertension, had aortic valve replacement. There were no hospital deaths and only one noncardiac death at follow-up in Group 3 patients, and 11 of the 12 surviving patients were in New York Heart Association functional class I. We conclude that pulmonary hypertension is common in isolated aortic stenosis and is related to an elevated left ventricular end-diastolic pressure, frequently with preserved systolic function. Surgical results are excellent.

Pulmonary hypertension in severe aortic stenosis. Incidence, mechanisms, clinical and surgical implications.

Pulmonary arterial hypertension in aortic stenosis (AS) is considered uncommon, and the possible mechanisms involved in its insorgence are only speculative. We analyzed a group of 95 patients with severe AS (mean systolic gradient greater than or equal to 50 mmHg and/or aortic valve area less than or equal to 0.7 cm2) studied by standard hemodynamic techniques. In the study group the incidence of pulmonary hypertension was 50.5%. We divided the overall population in: Group I (47 patients), with systolic pulmonary artery pressure (PAP) less than or equal to 30 mmHg; Group II (33 patients), with moderate hypertension (PAP 31-50 mmHg); Group III (15 patients), with severe hypertension (PAP greater than 50 mmHg). Subjects with pulmonary hypertension were slightly older, and had more severe obstruction to left ventricular (LV) outflow. Impairment of LV diastolic function in the presence of pulmonary hypertension was expressed by a highly significant increase of LV end-diastolic pressure (p less than .001); reduced ejection performance was represented by a significant decrease of ejection fraction (p less than .01). Pulmonary vascular resistances also appeared to be increased. The correlation between variables showed PAP to be strongly correlated in a positive way to the LV end-diastolic pressure, and in an inverse way to the LV systolic performance (p less than .001 for both). Less striking was the correlation of pulmonary vascular resistances to LV diastolic and systolic function: a reactive and reversible vasoconstriction seemed likely. Surgery was not performed in 8 of the 95 patients: 5 of them died shortly after diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Spinal cord ischemia following operation for traumatic aortic transection.

The danger of irreversible ischemic damage to the spinal cord following repair of traumatic aortic rupture has prompted many techniques designed to decrease this risk. Surgical repair was performed on 41 consecutive patients, using four different methods. These included: group 1 (15 patients), left-heart pump bypass with systemic administration of heparin; group 2 (7 patients), heparinized shunt from the ascending aorta to the descending aorta or to the femoral artery; group 3 (14 patients), heparinized shunt from the left ventricle to the aorta or femoral artery; group 4 (5 patients), aortic cross-clamp only. Spinal cord ischemia was not seen in groups 1 or 2, but paraparesis or paraplegia developed in 4 patients in group 3. Severe shock accompanied rupture in all patients in group 4, and no time was taken for a shunt or bypass. Four of the 7 deaths occurred in the operating room in patients who had arrived moribund and in severe shock. In our experience, shunts from the left ventricle to the aorta have failed to protect the spinal cord against ischemia. Left-heart bypass or aorta-to-aorta shunts are now our procedure of choice.

Rest and exercise hemodynamics following aortic valve replacement. A comparison between 19 and 21 mm Ionescu-Shiley pericardial and Carpentier-Edwards porcine valves.

When aortic valve replacement is performed in a patient with a small anulus, significant obstruction of the left ventricular outflow tract may remain. Most prostheses are obstructive in the smaller sizes, and enlargement of the aortic anulus may be required to allow placement of a larger valve. To evaluate the hemodynamic performance of two commonly used tissue prostheses, the Ionescu-Shiley pericardial and Carpentier-Edwards porcine valves, 22 patients with either the 19 or 21 mm size were electively studied at rest and after exercise at a mean of 15 months after operation. The resting mean transvalvular gradient for 19 mm Ionescu-Shiley pericardial valves (n = 7), 10.6 +/- 9.2 mm Hg, was significantly lower than that for 19 mm Carpentier-Edwards valves (n = 3), 33.3 +/- 2.1 mm Hg, p less than 0.01. Following exercise, the mean gradient for 19 mm Ionescu-Shiley pericardial valves rose only to 13.8 +/- 8.5 mm Hg. No exercise data were available for the 19 mm Carpentier-Edwards valve. Among patients with 21 mm Ionescu-Shiley pericardial valves (n = 7), the mean transvalvular gradient at rest was 5.6 +/- 9.5 mm Hg, not significantly different from that of patients with 21 mm Carpentier-Edwards valves (n = 5), 9.8 +/- 18.3 mm Hg. After exercise, the gradients rose to 16.0 +/- 10.0 mm Hg and 25.5 +/- 23.8 mm Hg for the Ionescu-Shiley pericardial and Carpentier-Edwards valves, respectively (no statistical significance). Cardiac index was not different between groups. Gradients were not significantly higher in patients with body surface areas greater than 1.5 m2. It is concluded that the 19 and 21 mm Ionescu-Shiley pericardial valves possess excellent hemodynamics, even after exercise. This valve appears hemodynamically superior to the Carpentier-Edwards valve, particularly in the 19 mm size. Procedures to enlarge the aortic anulus are usually unnecessary when small Ionescu-Shiley pericardial valves are used, even in patients who have large body surface areas.

Primary osteosarcoma of left atrium: complete surgical excision.

A patient with primary osteogenic sarcoma of the left atrium with clinical features of severe congestive heart failure is described. The operative procedure required excision of the posterior atrial wall in continuity with the left pulmonary veins. The resultant defect in the atrium was reconstructed with the left atrial appendage. The left pulmonary artery was ligated, and the lung was removed at a subsequent procedure. The patient survived operation but subsequently was found to have distant metastasis. He died seven months after the operation.

Neurologic complication following coronary artery bypass. The role of atherosclerotic emboli.

Neurologic complications continue to plague aortocoronary bypass operations. All patients undergoing isolated coronary artery bypass procedures over a four-year period at the Upstate Medical Center were reviewed. Eight of 893 patients sustained a cerebrovascular accident following operation (0.9%). In 5 patients, the etiology was felt to be calcific and atherosclerotic debris from the ascending aorta. Air embolism occurred in one patient, and the etiology was unknown in 2 patients. Various methods to deal with the diffusely atherosclerotic aorta are discussed.

Can we trust the direct radial artery pressure immediately following cardiopulmonary bypass?

Reversal of the usual relationship between aortic and radial artery pressure can occur in patients following cardiopulmonary bypass. Radial systolic (and often radial mean) pressures were lower, relative to aortic pressure, after cardiopulmonary bypass than before bypass in all 18 patients studied. The systolic pressure difference (aortic minus radial) was large enough to be of clinical concern (12-32 mmHg) in 13 patients. The change persisted for 10-60 min, gradually returning toward normal. The change temporally was associated with warming at the end of cardiopulmonary bypass and lowered forearm vascular resistance. Relative forearm vascular resistance (x) predicted the systolic aortic minus radial pressure difference (y) by the equation y = -0.34x + 17 for all patients (r = -0.49, P less than 0.001). The authors conclude that radial artery pressure does not accurately reflect central aortic pressure in the immediate postbypass period.

Injuries to arterial branches of the aortic arch.

Exposure of arch branches for repair following trauma can be difficult. Seven patients with blunt injuries and 5 with penetrating injuries underwent repair of the innominate, common carotid and subclavian arteries. Common associated injuries included head injury, hemopneumothorax, lung contusion, long bone fractures and brachial plexus injury. Widened mediastinum was seen in 5 patients. Six patients with innominate, right subclavian and right common carotid injuries were approached through sternotomy with extension into the right side of the neck. Posterolateral thoracotomy was used to reach the proximal left subclavian artery in 2. Combined supra- and infraclavicular incision were utilized for the distal subclavian artery in 4. Eleven patients are alive, one to 7 years after surgery. One died of an unrelated cause. Head injuries complicated the postoperative management in 4 of the 7 patients with blunt trauma. Two patients with brachial plexus injury continued to have neurologic deficits. All arterial repairs have remained patent and there have been no graft infections.

Adverse prognostic effect of N2 disease in treated small cell carcinoma of the lung.

We reviewed survival of patients with clinically localized small cell carcinoma of the lung treated by surgical resection, combination chemotherapy, and prophylactic cranial irradiation. Long-term survival was defined as continuing complete remission 30 months after the start of treatment. Initial TNM staging determined the course of treatment. Ten patients with disease in Stages I and II were treated over 30 months ago by initial resection followed by the full course of chemotherapy. Only one has had a relapse, whereas 80% remained disease-free at 30 months. Five of these patients have passed 5 years. Four patients with T3 N1 disease were treated by two cycles of chemotherapy, surgical resection, and cranial irradiation plus resumption of chemotherapy thereafter; two remained in remission at 30 months. Sixteen patients initially with N2 disease were treated according to the same schedule; 10 of the 16 underwent successful resection. All 16 patients have had a relapse, but the relapse occurred very late in three--at 27, 30, and 37 months. The reasons for the apparently poor prognosis of N2 disease are not clear. Considerations of tumor response kinetics and somatic mutation suggest that these biologic factors are fundamentally responsible. Other studies may find disease control achieved in a very few patients with N2 disease.

Approach in the management of atrial myxoma with long-term follow-up.

Between 1972 and 1982, 9 patients underwent successful excision of atrial myxomas at the Upstate Medical Center. Eight patients had a left atrial myxoma and 1 a biatrial myxoma. There were 5 female and 4 male patients ranging from 16 to 63 years of age. Preoperative findings consisted of cerebral or peripheral emboli, congestive heart failure, and nonspecific symptoms. Diagnosis was confirmed by echocardiography and angiography in all but 1 patient. A biatrial operative approach was utilized in all patients except 1. Complete excision of the tumor with a cuff of normal tissue was performed. All heart chambers were carefully explored for presence of multicentric myxomas or tumor debris. There were no operative deaths or intraoperative embolizations. Follow-up has been 1 1/2 to 11 years. There has been 1 late noncardiac death. All patients underwent echocardiography postoperatively with no recurrence. The risk of intraoperative embolization and late recurrence is minimal with the biatriotomy technique. Two-dimensional echocardiography is extremely accurate in early diagnosis of myxomas and in the late follow-up of patients.