Transthoracic intraaortic balloon pump support: experience in 39 patients.

From June, 1982, through July, 1985, 39 (1.5%) of 2,570 patients undergoing open-heart procedures required insertion of a transthoracic intraaortic balloon pump (IABP). In all of these patients, a percutaneous attempt failed or was contraindicated. There were 24 (62%) men and 15 (38%) women. The mean age was 64.9 years. Five patients (13%) sustained complications potentially related to the transthoracic IABP. They included mediastinal infection in 1 patient (2.5%), balloon rupture in 2 patients (5%), and cerebrovascular accidents in 4 patients (10%). The overall survival was 44%. Survival for the group of patients weaned from transthoracic IABP support was 17 (81%) of 21. There were no deaths directly related to the transthoracic IABP. The transthoracic IABP was removed under local anesthesia without sternotomy in 19 (90%) of the patients weaned and with formal sternotomy in the remaining 2 (9%). In a select group of patients requiring intraaortic balloon counterpulsation, the use of the transthoracic IABP is a reasonable second choice for patients in whom other methods of balloon support are not feasible.

Disc embolization of Björk-Shiley mitral prosthesis without strut fracture.

Strut fracture with subsequent embolization of the Björk-Shiley mitral prosthesis is a rare but recognized complication. A case of disc embolization without strut fracture was managed successfully by early surgical intervention. The preoperative chest x-ray film demonstrating apparently intact major and minor struts underscores the importance of a high index of suspicion to make an early diagnosis.

"Tire patch" angioplasty: a new method of arterial repair.

A method of controlling a problematic aortotomy suture line using an onlay patch of polytetrafluoroethylene (Gore-Tex) is described. This method has been used successfully in several instances with good control of bleeding and no complications.

Endotracheal intubation using percutaneous retrograde guidewire insertion followed by antegrade fiberoptic bronchoscopy.

Although endotracheal intubation can usually be performed readily by many medical and paramedical personnel, it may be very difficult in situations such as trauma, hemorrhage, or deformity. We inserted an endotracheal tube over a retrograde guidewire in a patient with a cervical deformity. Published reports of retrograde intubation are reviewed.

Reoperation for stenotic saphenous vein bypass grafts without cardiopulmonary bypass or shunt.

From October 1982 through February 1985, six patients have undergone seven reoperative revascularization procedures for stenosis of coronary artery vein bypass grafts without the use of cardiopulmonary bypass or intraoperative shunt. All patients had prior coronary artery saphenous vein bypasses, ranging from 2 months to 5 years preoperatively. All patients survived reoperation and there was no morbidity. Patients have been followed-up to 26 months. One patient underwent postoperative cardiac catheterization at 1 year, which revealed a patent interposition graft, and one patient had a second operation for restenosis of a vein graft. To decrease the risk of morbidity and mortality in reoperative procedures for saphenous vein graft stenosis, a technique is described that avoids the use of cardiopulmonary bypass or intraoperative shunt. This technique has been used successfully for seven reoperative revascularization procedures and is recommended for selected cases.

Effect of phentolamine in controlling temperature and acidosis associated with cardiopulmonary bypass.

This study assessed the effects of phentolamine on rewarming patterns and metabolic acidosis in 37 patients subjected to hypothermia during cardiopulmonary bypass for the performance of aortocoronary bypass grafting. An additional 16 patients undergoing the same surgery received no phentolamine and served as a control group. In all patients, sodium bicarbonate (44.6 mEq) was administered only when the negative base excess was 3.0 mEq/L or greater. Sixty-eight percent of the patients receiving phentolamine and 56% of the control patients exhibited a uniform rewarming pattern in which the rectal, hand, and foot temperatures increased in parallel. In 32% of the patients receiving phentolamine and in 44% of the control patients, rectal and hand temperatures increased more than foot temperature during rewarming. Analysis of base excess values in the subgroups of patients with similar rewarming patterns indicated that base deficits were significantly decreased in patients receiving phentolamine. Phentolamine administration was also associated with significantly lower blood lactate levels and sodium bicarbonate requirements, as well as improvements in overall appearance and mental status. These data suggest that the routine use of phentolamine in patients undergoing cardiopulmonary bypass may be associated with more uniform body cooling and rewarming and improved tissue perfusion.

Sigmoidal ulcer as a cause of acute colonic obstruction.

A case of primary nonspecific ulceration of the sigmoid colon initially manifesting as acute colonic obstruction is presented. Other possible etiologies of acute sigmoidal obstruction are discussed.