Portal vein thrombosis associated with coronary artery bypass surgery.

Portal vein thrombosis is a rare but well-known complication after abdominal surgery. To our knowledge, there have been no reports about this complication after cardiopulmonary bypass surgery. This can probably be explained by the variety of clinical pictures and difficulties in the establishment of a diagnosis of portal vein thrombosis. Among the possible trigger factors, bacteremia, that is usually caused by Bacteroides fragilis or by Escherichia coli, has been assessed. In this case, several blood culture specimens and fluid from abdominal paracentesis consistently grew coagulase-negative staphylococci which have been proved to be one of the most common pathogens in postoperative infection after cardiac surgery. The patient received clopidogrel before and after coronary artery bypass grafting. We speculate that in this clinical situation associated with coagulase-negative staphylococcal bacteremia, clopidogrel resistance may play an important role. The natural history of portal vein thrombosis in this case is complicated by massive fatal gastrointestinal bleeding from rupture of the esophageal varices. Emergency endoscopic therapy with esophageal variceal ligation, injection of a sclerosing solution and using of vasoconstrictive agents helped only in the first episode of bleeding. Portal vein thrombosis after coronary artery bypass grafting is a serious complication. The clinical picture of portal vein thrombosis may vary greatly and the presence of this condition should be suspected when faced with abdominal pain with gastrointestinal bleeding of unknown origin and sepsis.

Delayed postoperative paraplegia complicating repair of type A dissection.

We describe the very rare event of delayed transient paraplegia after repair of type A dissection of the aorta and discuss therapeutic options. We also suggest insertion of a spinal catheter as soon as there are signs or symptoms of spinal cord injury to drain spinal fluid and maximize the effect of elevated spinal cord perfusion pressure.

Ventricular aneurysm repair: a new approach.

Repair of chronic left ventricular aneurysm or acute rupture of the heart after myocardial infarction is associated with technical difficulties and major morbidity and mortality. We describe a new endoventricular repair for both conditions. The repair consists of externally covering a Duran ring with Dacron and internally lining it with autologous pericardium. The modified ring is then sewn into the neck of the lesion. The technique is rapid, simple, and hemostatic. After repair of the chronic aneurysm, ventricular hemodynamics are improved during both diastole and systole. We have performed this technique in two patients with chronic aneurysm and one with subacute rupture.

Phrenic nerve injury after coronary artery grafting: is it always benign?

BACKGROUND: The purpose of this study was to evaluate the effect of phrenic nerve injury (PNI) occurring during coronary artery bypass grafting in patients with major chronic obstructive pulmonary disease (COPD). METHODS: Over a 42-month period, 1,303 patients underwent primary coronary artery bypass grafting. Sixty-seven (5.14%) had major COPD, and 29 (43.3%) of these 67 sustained PNI (group I). These patients were matched for age and ejection fraction with 29 CABG patients with COPD but without PNI (group II), 29 patients without COPD but with PNI (group III), and 29 patients with neither COPD nor PNI (group IV). The groups were compared on the basis of preoperative and operative factors and immediate and midterm morbidity and mortality. RESULTS: There were no significant differences between the groups with respect to hypertension, diabetes, ejection fraction, number of grafts, internal mammary artery use, cardiopulmonary bypass time, and ischemic time. Postoperatively, group I had a longer total hospitalization (group I, 11.7 days; group II, 7.8 days; group III, 7.8 days; and group IV, 6 days; p = 0.0001) and stay in the intensive care unit (I, 3.6 days; II, 2.2 days; III, 2.1 days; and IV, 1.2 days; p = 0.0023). More patients in group I required reintubation (I, 37.9%; II, 3.4%; III, 6.9%; and IV, 0%; p < 0.0001). Mean follow-up was 32.8 months (range, 7 to 48 months). Group I had more hospital readmissions (I, 78; II, 50; III, 61; and IV, 28; p < 0.007) and lower cumulative survival (I, 60.6%; II, 93%; III, 96.8%; and IV, 100%; p < 0.0015) compared with the other groups. CONCLUSIONS: In patients with COPD, PNI during coronary artery bypass grafting has a major negative impact on immediate and midterm results.

Effect of systemic vasodilators on internal mammary flow during coronary bypass grafting.

BACKGROUND: The effect of vasodilators on acute flow in the internal mammary (IMA) is unclear. Topical vasodilators show no effect on acute flow when the distal segment of the IMA is resected. The purpose of this study was to evaluate the effect of systemic vasodilators when this segment is resected. METHODS: We studied 60 patients with proximal anterior descending coronary artery lesions in whom the left IMA was harvested for grafting to the left anterior descending coronary artery. The patients were divided into six groups (n = 10), based on which of the following agents were studied: normal saline solution, nitroglycerin, nitroprusside, dobutamine, dopexamine, and amrinone. After harvesting, the IMA was trimmed as proximally as possible (and at least 3 cm proximal to the bifurcation), and free flow was measured before any pharmacologic intervention (flow 1). Systemic infusion of one of the six agents commenced. A mean of 17 +/- 3.4 minutes after infusion began, with a comparable cardiac index, a second measurement of IMA flow was taken (flow 2). Hemodynamic measurements for each flow, including blood pressure, heart rate, and cardiac output, were taken. RESULTS: A significant increase in IMA flow was noted for those patients receiving nitroglycerin (93.5 versus 106.8 mL/min; p = 0.025), and a significant decrease in flow was noted for those receiving nitroprusside (91.0 versus 78.2 mL/min; p = 0.042). The effects remained significant when corrected for cardiac index and compared with the normal saline solution group. No other systemic agents tested significantly affected the IMA flow (dobutamine, 83.8 versus 85.0 mL/min; dopexamine, 101.8 versus 91.4 mL/min; amrinone, 75.4 versus 79 mL/min; normal saline solution, 85.8 versus 84.6 mL/min). CONCLUSIONS: Resection of the distal segment of the IMA and the use of intravenous nitroglycerin optimizes the flow in IMA grafts.

The meaning of equivocal pancreatic cytology in patients thought to have pancreatic cancer.

INTRODUCTION: Fine needle aspirations (FNAs) and endoscopic retrograde cholangiopancreatography (ERCP)-guided brushings (BRUSH) are useful tools in the differentiation between malignant and benign disease of the pancreas. Once the decision to obtain a cytologic confirmation of one's clinical suspicion is made, the interpretation of the findings, especially an equivocal or negative cytology finding, can be unclear. This study seeks to evaluate the utility of cytologic studies in the evaluation of a patient with suspected pancreatic malignancy. METHODS: A retrospective review of 224 cytologic reports, including 174 FNAs and 50 BRUSHs, from all pancreatic FNAs and BRUSHs performed between January 1989 and June 1995, was performed. Subsequent confirmation of the cytologic diagnosis was made either by histologic or strict clinical criteria. RESULTS: Forty-three percent of the cytologic reports were read as malignant, all others reported as suspicious, atypical, or negative. All cytology studies read as malignant and all FNAs reported as suspicious were histologically or clinically confirmed to be malignant. Of those reported as atypical or negative, 55% and 49% were confirmed to be malignant. Both FNA and BRUSH were 100% specific, 75% sensitive, and 80% accurate. CONCLUSIONS: We conclude that a cytological diagnosis of malignant or suspicious is reliable and useful for further therapy planning in the patient suspected to have a pancreatic malignancy. The reason for the cytologic tests was a strong clinical suspicion, therefore, a high incidence of cancer was found in the patients with atypical or negative readings. A diagnosis of atypical or negative is equivocal and requires further diagnostic maneuvers, frequently including surgery, to make the definitive diagnosis.

Chronic obstructive pulmonary disease in patients undergoing coronary artery bypass grafting.

The purpose of this study was to evaluate the effect of chronic obstructive pulmonary disease on patients undergoing coronary artery bypass grafting. Between June 1991 and June 1993, 651 patients underwent coronary artery bypass grafting: 37 patients (group I) had significant chronic obstructive pulmonary disease. These patients were compared with 37 matched control subjects (group II). Comparison of the groups was made with regard to postoperative morbidity and mortality. Quality of life of survivors was compared at the last follow-up. More patients in group I had preoperative arrhythmias (8 versus 1, p = 0.014). Group I patients had lower values of forced expiratory volume in 1 second (1.366 +/- 0.032 L versus 2.335 +/- 0.49 L, p < 0.0001), lower oxygen tension (63.5 +/- 8.2 versus 79.1 +/- 13.4 mm Hg, p = 0.001), and higher carbon dioxide tension (44.8 +/- 6.5 mm Hg versus 39.7 +/- 3.6 mm Hg, p = 0.001). After operation patients in group I had a longer hospital stay (8.1 +/- 3.6 days versus 6.6 +/- 1.7 days, p = 0.0236) and longer intensive care unit stay (2.64 +/- 0.9 days versus 1.23 +/- 0.49 days, p = 0.0001). More patients in group I required prolonged intubation (7 versus 1, p = 0.0278) and reintubation (5 versus 1, p = 0.088). More patients in group I had significant arrhythmias (27 versus 9, p < 0.0001). During a 16-month follow-up period, five patients in group I died, whereas none in group II died (p = 0.0271). Four deaths were related to arrhythmias. More group I patients were not functionally improved by the operation (17 versus 3, p = 0.0056). The results of coronary artery bypass grafting in patients with significant chronic obstructive pulmonary disease were not favorable in midterm follow-up. A major cause for morbidity and mortality was postoperative arrhythmias.

Effect of topical vasodilators on internal mammary arteries.

The internal mammary artery (IMA) is the conduit of choice for grafting the left anterior descending artery. However, arterial spasm and reduced early flow has been a cause of postoperative morbidity. The purpose of this study is to evaluate the effect of vasodilators on IMA flow. Fifty patients who had the IMA harvested in preparation for bypass grafting were studied. The IMA was mobilized from the subclavian vein to below the bifurcation of the IMA. The artery was prepared for grafting at least 3 cm proximal to the bifurcation. The IMA was allowed to bleed freely, and flow was determined (flow 1). The patients were divided into five groups: group I (n = 10) had 10 mL of saline solution applied topically to the IMA; group II had topical papaverine (5 mg/10 mL normal saline solution) applied to the IMA; group III had nitroglycerin (5 mg/10 mL normal saline solution) applied to the IMA, group IV had sodium nitroprusside (2.5 mg/10 mL) applied to the pedicle, and group V had 5 mL of papaverine mixed in 5 mL of saline solution injected into the periarterial tissues of the IMA pedicle. Before cardiopulmonary bypass, the flows were remeasured (flow 2). With each measurement, hemodynamic parameters were recorded. The time between measurements was recorded. There was no difference in blood pressure or pulse at the time of measurement.(ABSTRACT TRUNCATED AT 250 WORDS)

Anatomic considerations in closed transatrial cannulation of the coronary sinus.

Successful closed transatrial coronary sinus cannulation is dependent on a proper catheter insertion site and proper catheter direction. Accurate anatomic landmarks are described to provide a reproducible cannulation site and catheter direction. This results in consistent successful cannulation of the coronary sinus.

A safe and rapid method for the mobilization of the internal mammary pedicle.

A simple method is described for the safe and rapid dissection of the internal mammary pedicle. The essential feature of this technique is the use of Silicone Rubber devices, for the identification and retraction of the internal mammary pedicle during its preparation.

Computerized interactive morphometry of brushing cytology specimens.

Forty-two bronchial brushing cytology specimens were evaluated by a video-based computerized interactive morphometry (CIM) system with an interactive peripheral consisting of a touch-sensitive screen mounted over a high-resolution video monitor. The system was programmed to allow a trained observer to rapidly measure nuclear and cytoplasmic profile diameters of randomly selected cells and to calculate their nuclear-cytoplasmic ratios. The specimens included 13 cytologic slides with no malignant cells present, 14 with non-small cell carcinoma cells and 15 with small cell carcinoma cells. The cases were divided into two groups: a training set composed of slides with "known diagnosis" and a test set of slides with "unknown diagnosis". A data set was constructed with the measurements from the cases with "known diagnosis," and an algorithm that allowed the classification of cases by hierarchical analysis was developed. The data was also analyzed with statistical methods of classificatory discriminant analysis. Utilizing the information in the data base, the slides with "unknown diagnosis" were classified individually; all cases were correctly classified by the procedures. Potential applications of CIM in cytology are discussed.

Computerized interactive morphometry as an aid in the diagnosis of pleural effusions.

A morphometric study of cytologic preparations from patients with benign and malignant (mesothelioma and carcinoma) pleural effusions is reported. The routine cytologic smears from these specimens were studied with a new system of video-based computerized interactive morphometry (CIM) that allows the measurements of real-time images of cell profiles by the simple procedure of touching the two extreme points of a diameter of interest on a touch-sensitive screen. For each cell, the nuclear profile diameter (NPD) and the cytoplasmic profile diameter (CPD) are measured and categorized into classes with 2-microns intervals; the NPD/CPD ratio is also calculated. The mean NPD is calculated for the specimen after measurement of 100 cells. The data were interpreted by two independent methods: a statistical method of discriminant analysis that classifies the lesions as benign, carcinoma or mesothelioma and provides a probability statement of membership in a particular diagnostic class and an ad-hoc algorithm that categorizes the effusions as benign or malignant based on hierarchic analysis. A data base derived from study of the first 24 cases was constructed and utilized for the test classification of the second 24 cases, which were treated as specimens of unknown diagnosis. The discriminant analysis correctly classified 21 of the 24 test cases into their proper diagnostic groups. The algorithm for a computer-generated pathologic diagnosis correctly identified 47 of the 48 cases as benign or malignant. The technical advantages of video-based CIM over the existing morphometric methods are discussed.

Coarctation of the aorta in infancy.

Twenty-five infants under 1 year of age (mean weight 3.4 kg) underwent repair of coarctation of the aorta between the years 1965 and 1982. Three patients had coarctation only, three had coarctation with patent ductus arteriosus (PDA), and 19 had associated intracardiac anomalies. Eleven patients underwent resection of the aorta and end-to-end anastomosis. Eight had subclavian flap arterioplasty, five had patch graft arterioplasty, and one had subclavian-to-aortic anastomosis. Additional procedures were performed on seven patients: banding of the pulmonary artery on one, repair of total anomalous pulmonary venous drainage on one, mitral valve replacement on one, aortic valvotomy on one, and aortic valvotomy plus pulmonary artery banding on one. Twenty-one survived the operation. All patients who died had associated intracardiac anomalies. The 21 survivors have been followed from 3 months to 13 years, with three late deaths that were associated with intracardiac anomalies. Five of the survivors underwent additional second operations: one had repair of the re-coarctation, one had replacement of the prosthetic mitral valve, one had aortic valvotomy, and two had pulmonary artery debanding and closure of a ventricular septal defect. Two of the 18 surviving patients have mild hypertension associated with a residual gradient. The others are in good health.