Cocaine abuse and coronary artery dissection.

A 33-year-old man with a history of recent cocaine use presented with dissection of the left main coronary artery extending distally to involve the left anterior descending (LAD) and circumflex arteries. He required emergency four-vessel aortocoronary bypass, which was uncomplicated.

Reduction of leg wound infections following coronary artery bypass surgery.

OBJECTIVE: To reduce the rate of infection at the saphenous vein harvest site after coronary artery bypass surgery, to identify predictors of infection and to determine the best method for leg wound closure. DESIGN: A randomized clinical trial was undertaken to determine the best technique for reducing the postoperative leg wound infection rate. Patients were allocated to one of four leg wound closure methods: staples, close immediately; staples, close after protamine administration; subcuticular sutures, close immediately; and subcuticular sutures, close after protamine. Risk factors evaluated were age, sex, diabetes, obesity, peripheral vascular disease, reoperation, time in surgery, wound length, wound depth, time that the wound was open, wound quality and harvest site. SETTING: The Walter C Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta. PATIENTS: All consenting patients undergoing elective coronary artery bypass surgery involving saphenous vein harvesting were considered for the study. Exclusion criteria were insertion of a drain, insertion of an intra-aortic balloon pump in the index limb and inability to complete follow-up at the authors' centre. Eighty patients were initially enrolled, with 77 completing the study. INTERVENTIONS: Patients underwent standard saphenous vein harvesting followed by wound closure as indicated by the study group. MAIN RESULTS: The major infection rate was reduced from 13% to 3% (P = 0.02). Each closure method was equally effective, and wound depth was the only factor related to infection. CONCLUSIONS: Leg wound infections continue to be a major source of morbidity after coronary bypass surgery.

Impact of managed waiting for coronary artery bypass graft surgery on patients' perceived quality of life.

BACKGROUND: Current demand for CABG surgery remains high, often exceeds available resources, and has led to the development of managed waiting lists. This study was designed to determine how being placed on a managed waiting list for > 6 weeks for CABG surgery affected patients' perceived quality of life in a Canadian center. METHODS AND RESULTS: Telephone interviews were carried out in the setting of a large urban hospital in northern Alberta. All participants were identified from 3 waiting lists of adult patients waiting for open heart surgery. A master list of patient statements was compiled to formulate the 47-item Waiting List Impact Questionnaire (WLIQ). A total of 102 patients completed the WLIQ by telephone interview. Patients (87.5%) indicated that their quality of life had deteriorated since being placed on the waiting list. None of the patients perceived an improvement in their quality of life. Frequency data for the WLIQ provided a broad, multidimensional perspective of the experience of waiting for CABG surgery and its impact on perceived quality of life. Negative impact was found in each of 5 main themes: employment and income, physical stress, social support, frustration, and quality of life. CONCLUSIONS: This study indicates that patients perceived a negative impact on their quality of life after being placed on a managed waiting list for CABG surgery. In the allocation of healthcare resources, attention should be paid to the impact of waiting on patients' physical well-being as well as on quality of life.

Pulmonary resection for lung trauma.

BACKGROUND: Pulmonary resection is rarely required for trauma, and its mortality is reportedly high. METHODS: A 10-year retrospective review of pulmonary resections for trauma was done. RESULTS: Of 2,455 patients with chest trauma, 183 (7.4%) underwent thoracotomy and 32 (1.3%) required pulmonary resection. Mean age was 28.4 years and mean injury severity score was 24.5. Mechanism of injury was stab wound in 14 patients, gunshot wound in 6, and blunt trauma in 12. Blunt trauma patients had a higher injury severity score (29.6) than penetrating trauma patients (21.4), but this was not significant (p < 0.07). Indications for thoracotomy were hemorrhage in 24 patients, airway disruption in 4, and other indications in 4. Operations consisted of wedge resection (19 patients), lobectomy (9), and pneumonectomy (4). Four (12.5%) patients (pneumonectomy, 2; lobectomy, 1; wedge, 1) died. Mortality for pneumonectomy was 50%, but this was not significantly higher than for lesser resections. Blunt trauma had a higher mortality (33%) than penetrating trauma (0%) (p < 0.02). Nonsurvivors had higher injury severity scores (44.2) than survivors (21.6) (p < 0.001). CONCLUSIONS: Pulmonary resection is infrequently required for lung injury. Overall mortality is lower than previously reported, but pneumonectomy has a high mortality. Blunt trauma has a higher mortality than penetrating trauma. Injury severity scores are higher for nonsurvivors than survivors; this shows the importance of associated injuries on outcome.

Government, university, and community collaboration to develop a cardiac surgery database and report of morbidity and mortality while waiting for open heart surgery.

The Provincial Advisory Committee on Cardiovascular Services was established in January of 1990 to advise concerning these services. One of the first tasks assigned was to monitor waiting times for cardiac surgery. Referring cardiologists categorized their patients into four priorities: emergency, urgent-inpatient, urgent-outpatient, and planned. Data of the southern Alberta centers for the past three years were analyzed for events while waiting for surgery. (Median time to event in days) M1=Myocardial Infarction EM=Emergency D=Day A hierarchy was used to assign the single most serious event for patients having more than one event: death>MI>readmission or change from urgent-inpatient to emergency. Events were frequent and unpredictable, particularly in outpatients. Categorization of patient suitable to wait at home for cardiac surgery is imperfect. The risk of having an event while on the waiting list is much greater for out-patients than in-patients: 12.8% (169/1323) versus 1.9% (19/1002). All adverse events for the in-patients occurred at four days--one day less than the proposed maximum waiting time. In the out-patient population, the median waiting time to experiencing adverse events ranged between 32 and 54 days. Target waiting times set by PACCS for these two categories is 14 and 56 days respectively. Total adverse events occurred to 8% of the patients on the waiting list. Median waiting time to experiencing an adverse event while on the list occurs much earlier than suspected: four days in urgent in-patients and 36 days for out-patients; well below the intended maximum of 56 days. This database proved invaluable for this important critical data collection. It is hoped it will serve as a model for similar future projects.

Angiosarcoma of the heart.

A 17-year-old boy presented with severe chest pain which partially subsided on anti-inflammatory medication. Five week later he was admitted with fully developed cardiac tamponade. Within five days surgical exploration revealed an nonresectable right atrial tumour. Management of angiosarcoma of the heart is discussed.

Antimicrobial prophylaxis for open heart operations.

Between 1986 and 1988, 450 adults undergoing coronary artery bypass, cardiac valve replacement, or both were enrolled into a prospective, randomized, comparative trial of cephalothin versus cefamandole as perioperative prophylaxis. They were assessed during their hospitalization and at 6 weeks and 6 months after discharge for postoperative infectious complications. Eleven patients had major postoperative infections including 5 with sternal wound infections (three bacteremic), 6 with bacteremia, 1 with prosthetic valve endocarditis, and 3 with severe venous donor graft site infections. Eight major infections occurred in patients receiving cephalothin prophylaxis and three in patients receiving cefamandole, with all five sternal wound infections occurring in the cephalothin group. Postoperative pathogens responsible for the major infections included gram-negative aerobes in 5 patients, Staphylococcus aureus in 4, and Staphylococcus epidermidis in 2. Preoperative colonizing staphylococcal isolates were not predictive of postoperative staphylococcal pathogens. Although there was no statistically significant difference in rate of major postoperative infectious complications using either cephalothin or cefamandole prophylaxis, there was a trend in favor of cefamandole. Gram-negative aerobes are becoming increasingly important pathogens in this setting.

Endoscopic diagnosis and treatment of postoperative bronchopleural fistula.

The diagnosis and closure of small postresection bronchopleural fistulae can be accomplished with selective bronchography and placement of fibrin sealant through the flexible fiberoptic bronchoscope. This method of diagnosis and closure of the bronchopleural fistula avoids both general anesthesia and a thoracotomy. This technique is successful in small bronchopleural fistulae and patients with multiple postresection bronchial stumps.

A five year study of the incidence of valve-related complications with the Omniscience cardiac prosthesis.

A total of 228 Omniscience cardiac valve prostheses were implanted in 210 patients at two hospitals in Canada from November, 1979 to August, 1984. The 184 operative survivors were followed for a mean duration of 28.5 months (maximum 62.7 months) and for a total of 438 patient-years. Actuarial analysis for AVR, MVR, and all patients showed survival probabilities at five years of 97.2%, 98.9%, and 97.0% respectively. The five-year actuarial probabilities of remaining free of any thrombotic complications were 96.9% for AVR, 96.4% for MVR, and 95.7% overall. When considering only serious thrombotic complications (thromboembolism with deficit or valve thrombosis), the event-free rates are 100% for AVR, 98.9% for MVR, and 98.6% for the overall patient group at five years. These rates for survival and freedom from thrombotic complication demonstrate the clinical safety and effectiveness of the Omniscience prosthesis. In addition, there were no cases of structural failure or intrinsic mechanical malfunction of the prosthesis.

Primary sarcoma of the pulmonary trunk: successful surgical intervention and prolonged survival.

We present a rare case of pulmonary trunk sarcoma in a young male in which the diagnosis was made antemortem. Total surgical removal of the tumor, including replacement of the pulmonary valve, was undertaken. This patient is the longest reported survivor of pulmonary trunk sarcoma and remains free of any signs or symptoms of recurrence. No adjuvant chemotherapy was required.

Alterations in plasma-, monocyte-, and lymphocyte-associated fibronectin during cardiopulmonary bypass surgery.

The changes in plasma fibronectin and IgG, and monocyte- and lymphocyte-associated fibronectin were studied in patients undergoing elective cardiopulmonary bypass surgery. A significant fall (P = less than 0.0005) in plasma fibronectin occurred during bypass, resulting largely from hemodilution as assessed by IgG concentrations, but also related to consumption of fibronectin. Plasma levels were still reduced 48 hours following the operative procedure, despite variable amounts of blood components infused in the immediate post-bypass period. Monocyte-associated fibronectin increased significantly (P = less than 0.05) during bypass, and lymphocyte-associated fibronectin levels decreased. Our studies confirm a reduction in circulating fibronectin in cardiac surgery, with accompanying fall in lymphocyte-associated levels presumed to reflect nonspecific adsorption. In contrast, the increased binding to monocytes may be an important functional aspect requiring further investigation, together with assessment of monocyte-macrophage function, before empiric use of cryoprecipitate therapy in these patients is recommended.

Computerized database for coronary bypass surgery.

A computer-assisted system has been developed to store, retrieve and analyze medical and surgical data on patients undergoing coronary bypass surgery. The analysis ranges from a simple summary tabulation to a more advanced prognostic evaluation of the risk of coronary bypass in an individual candidate for the operation. Data can be displayed on the terminal's screen or printed in a hard copy and used for clinical or administrative purposes. The system can be operated with no knowledge of computers or programming and requires only minimal typing skills.

Coronary artery bypass in patients under 40 years of age.

Coronary artery bypass surgery was performed in 92 patients, ranging in age from 20 to 40 years. The male-to-female ratio was 5:1. The operative mortality was 3.3%. Sixty-two patients were followed up for a mean of 3.5 years. Complete relief of angina was reported by 79% of patients and an additional 10% experienced some improvement. The survival rate at 3.5 years was 97%. The results favour myocardial revascularization in young adults.

Middle-latency auditory evoked responses during open-heart surgery with hypothermia.

Middle-latency auditory evoked responses (MLRs) were recorded from infants and adults before and during open heart surgery. Hypothermia was induced through perfusion cooling by cardiopulmonary bypass. In infants deep hypothermia (to 15 degrees C nasopharyngeal temp.) was often followed by the induction of total circulatory arrest. In adults nasopharyngeal temperatures of 25 degrees C were reached. The MLRs were elicited by unfiltered clicks presented through an insert type earphone and recorded with a vertex to ipsilateral earlobe electrode configuration. The MLRs proved to be resistant to muscle relaxation induced by pancuronium and to anesthesia induced and maintained in most cases by fentanyl. In most cases MLR peak latencies were progressively delayed as temperature decreased. Hypotension resulted in decreased MLR (Pa) amplitude.

Pulmonary resection in cystic fibrosis: a case report.

There is limited experience world wide in the management of patients with cystic fibrosis who undergo thoracotomy. Because of their shortened life-span and the diffuse nature of pulmonary involvement, resection is seldom performed for uncontrolled pulmonary infections. An 8-year-old boy with cystic fibrosis and a chronic infection of the right lung with abscess formation underwent pulmonary resection after 1 week of antibiotic therapy with tobramycin, ticarcillin and cloxacillin, and physiotherapy. Postoperatively, he was kept in the intensive care unit for 48 hours. Physiotherapy was begun immediately after operation and continued every 2 hours for the first day. The preoperative antibiotic therapy was continued. The postoperative course was smooth and the boy did well for 1 year. Over the next 6 months his condition deteriorated and he died 18 months after operation. Pulmonary resection should not be used in patients whose pulmonary infections can be controlled medically but may be of value for those with uncontrollable localized infections.

Carcinoid tumor of the thymus associated with recurrent pericarditis.

A 49-year-old man with carcinoid tumor of the thymus presented with the clinical picture of acute pericarditis. Recurrent bouts persisted after removal of the tumor without other evidence to indicate tumor recurrence. There were no associated manifestations of an endocrine disorder.

Extended aortic bypass.

At the University of Alberta Hospital, six patients recently underwent placement of Dacron bypass grafts from the ascending aorta to the infrarenal abdominal aorta or femoral arteries for a variety of vascular problems. The operations were performed in patients with (1) multiple aortic coarctations, (2) congenital aortic arch interruption and congenital mitral stenosis, (3) recoarctation of the thoracic aorta after previous coaractation repair (two patients), (4) aortoiliac occlusive disease in a patient with multiple previous abdominal operations including an abdominal-perineal resection and left lower quadrant colostomy, and (5) idiopathic retroperitoneal fibrosis and multiple previous operations on the abdominal aorta. Surgical access was through midline sternotomy and laparotomy incisions, and groin incisions were used as required. Careful attention was paid to placing as much graft as possible in an extraperitoneal position. All patients survived the operation and had essentially uneventful postoperative courses with good results. This technique has previously been described. However, attention is drawn to it once again as an excellent means of bypassing the thoracic and abdominal aorta in selected patients with complex vascular problems.

Hypothermic coronary perfusion for myocardial protection during aortocoronary bypass.

Numerous methods have been used in an attempt to prevent myocardial injury that results from the interruption of aortic flow during cardiac operations. The authors describe a relatively simple means of inducing cardioplegia during coronary bypass surgery by coronary perfusion with cold lactated Ringer's solution through the aortic root. When the results following the employment of hypothermic coronary perfusion for intraoperative cardioplegia were compared with those obtained without its use, the procedure was found to confer a degree of intraoperative myocardial protection and appeared to lead to a decrease in intraoperative myocardial infarction, subendocardial ischemia and intraoperative mortality.