Esophageal rupture complicated by a gastrocardiac fistula: review of the literature and report of a successfully treated case.

A 62-year-old man developed a fistula between the right ventricle and the stomach after Thal fundic patching of an emetogenic rupture of the esophagus. He underwent emergency surgical correction of the fistula and survived.

Dilation of difficult strictures of the esophagus.

In managing difficult esophageal strictures not amenable to the usual methods of dilation, a technique of fluoroscopic placement of a guide wire followed by controlled gradual dilation of the stricture has been described. The method is fully explained and is easily performed by a team of endoscopists-radiologists. Since this article was submitted, six additional patients have been dilated by the authors. In each, a stent was used to maintain patency of the strictured lumen.

A new multiprogrammable isotopic powered cardiac pacemaker.

A new multiprogrammable, isotopic-powered cardiac pacemaker was implanted in six patients as a custom device. Five were initial implants and one was a replacement. The patients were studied for up to two years. In five of the six cases it was found advantageous to change one of the programmable parameters. Multiprogrammability is obviously as important in an isotopic pulse generator as in a lithium unit, if not more so, because of the unit's greater longevity. Further studies are continuing in an FDA approved clinical trial.

A programmable pulse generator with high output option.

A new pulse generator, with a programmable high output option, was implanted in fifteen patients and studied for eight to ten months postoperatively. This feature is designed to combat exit block. It was useful in one patient who developed a form of exit block following a silent myocardial infarction. Muscle stimulation was rare, even though the system is unipolar. The high output option seems to be a desirable feature and should probably be available in all multiprogrammable pulse generators.

Fluoroscopic control for dilation of esophagogastric anastomotic stricture.

A radiologic technique is described for dilating a strictured side-to-side anastomosis between the upper esophagus and the fundus of the stomach. Traditional dilatation methods could not be employed because of the lateral position of the anastomosis.

Preparing an arterial patch graft.

Patch grafts frequently are used following endarterectomy for short-segment arterial disease. On occasion they are used to increase flow through stenotic areas where endarterectomy might be counterproductive. The following article delineates a fairly efficient way of preparing patch grafts in a reproducible manner. The technique involved in preparing, inserting, and suturing the patch graft is described.

A new wire-supported shunt for carotid endarterectomy.

An intraarterial shunt for cerebral protection during carotid endarterectomy is described. It combines the features of the U-shaped shunt of Hallin and the straight shunt of Sundt, and incorporates a side-arm that can be used for perfusion, irrigation, and intraarterial pressure. The shunt is a molded Silastic tube with wire coils at each end to prevent collapse, and its funicular collar and rim obviate sudden expulsion. Its use allows endarterectomy to be performed in a deliberate manner, permitting careful attention to prevention of an intimal flap and unhurried repair of the arteriotomy.

Permanent pervenous atrial sensing and pacing with a new J-shaped lead.

We have developed a new J-shaped lead for atrial pacing. The lead has silicone rubber tines which become entangled in the trabeculae and thereby anchor the lead firmly in the left atrial appendage. Later, scar tissue forms around the tines, rather than around the electrode, so that there is no problem with either lead displacement or loss of sensing.

Surgical management of life-threatening coronary artery disease: experience in 18 consecutive patients with left main trunk or equivalent coronary artery obstruction associated with an obstructed or a nondominant right coronary artery.

Eighteen patients with obstruction of the left main trunk or equivalent coronary artery associated with an obstructed or a nondominant right coronary artery were studied. All patients had coronary artery bypass surgery because of their symptoms and coronary anatomy. Five patients had coronary artery bypass without the use of preoperative elective intra-aortic balloon counterpulsation, and 3 of these patients had cardiac arrest prior to insertion of the grafts. The other 13 patients received elective intra-aortic balloon counterpulsation prior to induction of anesthesia and cannulation. None in this second group of patients developed any hypotensive episodes or cardiac arrest, and all have done well following the bypass operation. This experience suggests that the use of elective preoperative intra-aortic balloon assist in patients who have a very critical coronary artery obstruction is indicated in view of the high incidence of cardiac arrest observed in patients who did not receive the preoperative elective intra-aortic balloon support.

Preliminary clinical experience with a new radioisotope-powered cardiac pacemaker.

A small light-weight nuclear-powered pacer has been developed. The pulse generator weight 61 Gm. and occupies a volume of 33 sq. cm. It is a standard R-wave inhibited (VVI) demand pulse generator. The unit has met all United States and foreign atomic energy commission safety specifications including mechanical shock, industrial fire, accidental crush, cremation, impact, and corrosion. Its calculated life is in excess of 20 years. The unit has been shown to be insensitive to electromagnetic interference (EMI) over a wide range of commonly encountered sources of interference. An extensive dog testing program has been carried out and is continuing. The United States Atomic Energy Commission (AEC) has issued a license to conduct clinical trials. These began in October, 1974, and a total of 30 units of 30 units have been implanted so far. An equal number of chemical battery-powered pulse generators has been implanted in a control series of 30 patients. Preliminary results have been gratifying.