Carbon dioxide field flooding minimizes residual intracardiac air after open heart operations.

Transesophageal echocardiographic studies were used to monitor the presence of air bubbles in the heart after open heart operations. After cardiac valvular procedures all 22 patients managed with careful deairing procedures had persistence of air bubbles for at least 30 minutes and usually for 45 minutes. In 56 patients with CO2 field flooding, all foam disappeared in less than 1 minute in 48 patients and the remaining 8 had complete disappearance in 1 to 24 minutes. These observations demonstrate the ineffectiveness of the usual deairing maneuvers and the effectiveness of CO2 field flooding in displacing air.

Findlay implantable two-stage centrifugal pump.

The Findlay centrifugal pump is unique in its two-stage pumping mechanisms and in its complementary interrelationship of the stages to each other and to the exit system, and it forms an extremely efficient unit. The first stage is a lift force pump as an inlet. The second and major stage is a shear force pump. Twenty-six prototypes, many multiply modified, have been hand fabricated, and most have had classic pump function analyses. Six pumps have demonstrated minimal hemolysis (3.5-5 h). At modest rotation speeds, it pumps water up to 10 L/min. Forty-four acute studies in normal dogs have been performed with the Findlay pump in a ventricular assist system. Blood flows through the pump ranged from 1.2 to 4.5 L/min. The conclusion is that the Findlay pump has the ability to operate with low blood damage, performs at acceptable rotational speed with reasonable hydraulic and mechanical efficiency, and is small and implantable.

Iodized talc pleurodesis for the treatment of pleural effusions.

This prospective study was designed to determine the efficacy of iodized talc pleurodesis in patients with pleural effusions. Thirty-four patients underwent this treatment (three bilaterally) between October 1, 1989, and March 31, 1991. All patients had to have complete or nearly complete lung reexpansion after tube thoracostomy with fluid drainage less than 100 ml in 24 hours. A slurry containing 5 gm of talc and 3 gm of thymol iodide was instilled into the pleural space through the chest tube. Chest tubes were removed after complete reexpansion and clearing of the effusions, usually in 3 to 5 days. The patients' ages ranged from 26 to 88 years (average 50 years). Eighteen patients had lung carcinoma, two had mesothelioma, and one each had carcinoma of the ovary, breast, or anorectum, multiple myeloma, schwannoma, or Hodgkin's lymphoma. Two patients had an unknown adenocarcinoma primary and five other patients had acquired immunodeficiency syndrome. One patient had congestive heart failure. Nineteen patients had left, 12 had right, and three had bilateral pleural effusions. The effusion was serosanguineous in 26 and serofibrinous in eight patients. Serial chest radiography showed complete response in all patients. The period of follow-up ranged from 1 to 21 (average 4.9) months, with no recurrences. Twenty-three patients have died during the follow-up period, and there was no sign that reaccumulated pleural effusion existed in any, despite clinical evidence of systemic tumor progression. These observations indicate that intrapleural instillation of a slurry of iodized talc is a safe, adequate, and effective treatment for control of neoplastic or benign pleural effusions.

Superior vena cava syndrome associated with malignant mesothelioma.

A 70-year-old former shipyard worker presented with dyspnea and edema of the upper thorax suggesting the diagnosis of superior vena cava syndrome. Further evaluation revealed mesothelioma with both epithelial and spindled histologic patterns. The extensive mesothelioma had invaded the adventitia of the superior vena cava, the pleura of the lungs bilaterally, the superficial myocardium, and the liver. A terminal hyercoagulable state with great vein thrombosis was also contributory. To our knowledge this is the first documented case of superior vena cava syndrome associated with malignant mesothelioma.

Management of airway trauma. II: Combined injuries of the trachea and esophagus.

Twenty-four consecutive patients with combined injuries of the trachea and esophagus were operated on at the Tulane University Hospital and the Charity Hospital of New Orleans between 1967 and 1983. Only 3 of the injuries resulted from blunt trauma, and 1 of these patients had a total transection of both the trachea and esophagus; the remaining injuries were due to penetrating trauma (20 gunshot wounds; 1 stab wound). The combined lesions involved the cervical region in 20 patients and the thoracic esophagus and trachea or bronchus in 4. All patients underwent bronchoscopy; in recent years all have had esophagoscopy, because our experience indicates that esophagrams, which patients also underwent, have a high rate (12.5%) of false negative results. Operative techniques included a two-layer closure of all esophageal injuries, closure of the trachea with non-absorbable monofilament suture, and transthoracic or cervical drainage. Muscle flaps were used for suture line reinforcement. Associated operative procedures included tracheostomy (5), laparotomy (4), vascular procedures (5), neurologic procedures (2), and closed-tube thoracostomy (6). Five patients (21%) died in the perioperative period, 4 of 20 with combined cervical injuries, and 1 of the 4 with combined thoracic injuries. Deaths resulted from missed injuries to the esophagus (2 patients), a missed tracheal injury (1), associated vascular injury (1), and associated thoracoabdominal injury (1). Two patients experienced cervical esophageal suture line leaks, both of which sealed with conservative therapy. Clinical follow-up showed good results in 90% of the patients who survived.(ABSTRACT TRUNCATED AT 250 WORDS)

Diminished natural killer-cell activity of interstitial pulmonary cell populations from patients with carcinoma of the lung.

Natural killer-cell activity of fresh interstitial pulmonary cell populations from patients with squamous cell and adenocarcinoma of the lung and carcinoma metastatic to the lung was assessed and compared to that of apparently normal lung. No increase in the percentage of lymphoid cell populations was noted in the interstitium of lung contiguous with tumor, and the cytotoxic capacity of the cells present was depressed as compared to that of normal lung. Natural killer-cell function appears to be down regulated in lung cancer and may be amenable to therapies which activate such cytotoxicity in vivo.

Antiarrhythmic drugs: electrophysiological basis of their clinical usage.

Cardiac arrhythmias arise from abnormalities of impulse initiation or impulse conduction or both. A review of the electrophysiological mechanisms of the genesis of cardiac arrhythmias and of the electrophysiological principles of the treatment of the cardiac arrhythmias leads to: categorization of antiarrhythmic drugs into five classes based on their dominant cardiac electrophysiological actions; a series of categories of their effects on impulse initiation and impulse conduction in different types of cardiac cells; and a systematic approach to pharmacological management of cardiac arrhythmias.

Management of airway trauma. I: Tracheobronchial injuries.

One hundred six consecutive patients with injuries to the tracheobronchial tree who were admitted to the emergency room of the Tulane Medical Center Hospital or the Charity Hospital of Louisiana at New Orleans over a period of almost 20 years were analyzed retrospectively. Penetrating trauma of the neck or chest was reported in 100 of the patients, and only 6 had blunt trauma to the neck or thorax as the cause of injury. There were 18 deaths among the 106 patients (16.98%), including 11 (13.75%) of 80 with injuries of the cervical trachea. Seven (53.8%) of 13 with principal injuries of the thoracic trachea died; all 13 patients with major bronchial injuries survived. On admission to the emergency room, all patients had signs of airway compromise such as tachypnea, dyspnea, cyanosis, subcutaneous emphysema, or an abnormal respiratory pattern. Severe airway compromise was evident in 46 patients; 24 (23%) were treated with oral or nasal intubation, 19 (18%) with emergency tracheostomy, and 3 (2%) with intubation of a tracheal injury. Hemoptysis was an unreliable signal of serious injury, being present in only 28 of the patients. Patients who had major vascular injuries combined with trachea involvement were generally not salvageable. In regard to morbidity and mortality, the most common preventable errors were delay in diagnosis and treatment of tracheobronchial injuries, missed esophageal injuries, massive aspiration of blood, and abdominal vascular injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of thoracic aortobifemoral artery bypass grafting as an alternative procedure for occlusive aortoiliac disease.

A descending thoracic aortobifemoral artery bypass graft is proposed as an alternative procedure for revascularization of the lower extremities when an intra-abdominal approach is not feasible or is ill-advised. Three patients underwent a thoracobifemoral graft because of severe cardiopulmonary disease combined with multiple prior abdominal surgeries, complications of radiation, and sepsis. Patency of the aortobifemoral grafts was documented by palpable pulses and increased ankle: brachial ratios improving from 0.3 to 0.6, resulting in the relief of rest pain and obviating a limb-threatening situation.

Coronary bypass surgery in patients with circulating lupus anticoagulant.

Clinical and laboratory experience with circulating lupus anticoagulant in 3 patients undergoing coronary artery bypass procedures is reported. This circulatory anticoagulant inhibits activation of prothrombin by the prothrombin activator complex (factor Xa, factor V, and phospholipid). The presence of lupus anticoagulant was initially detected because of a prolonged activated partial thromboplastin time and a normal or mildly prolonged prothrombin time. The 3 patients underwent uncomplicated coronary artery bypass grafting and experienced no abnormal bleeding postoperatively. The lupus anticoagulant is a rare cause of bleeding after open-heart surgery. It appears to be a problem only when an additional coagulation defect is present.

Pulmonary microvascular leakage after microembolization and hemodilution.

This study examined the role of colloids versus crystalloids in pulmonary edema associated with the increased pulmonary microvascular permeability secondary to thrombin-induced pulmonary microembolism. Each of 23 healthy dogs received an intravenous injection of thrombin and a fibrinolysis inhibitor, which induced a microembolic state with increased (fivefold) pulmonary lymphatic flow and a lymph/plasma (L/P) protein ratio typical of a permeability change. Seven dogs received no treatment, eight received 15 ml/kg 10% dextran 40 (D40), and eight received 60 ml/kg Ringer's lactate solution (RL). Pulmonary water was measured serially by thermal conductivity and terminally by wet/dry weights. This preparation produced significant hemolysis; however, L/P ratios of hemoglobin approached unity in all groups. Initially there was hemoconcentration, which was reversed by RL and even more so by D40. Both D40 and RL temporarily raised the pulmonary artery and pulmonary artery wedge pressures to 15 mm Hg; D40 more than doubled the cardiac output of control or RL subjects--this was associated with a reduced pulmonary arteriolar resistance (P less than 0.05). In the early stage PaO2 was better maintained with D40 (P less than 0.02). Lymph flow increased and was comparable in all groups, as were lung water and lung weight, which tripled in all three groups. Results of this study indicated that in the presence of a pulmonary microvascular leak, colloids in doses that produced comparable microvascular pressures did not increase lung water and did not accumulate in the pulmonary interstitium. Colloids were superior to crystalloids in maintaining cardiac output, pulmonary vascular resistance, and oxygen tension in the early period after microembolism.U

Relationship between preoperative pulmonary function tests and complications after thoracotomy.

Simple spirometric testing remains useful for the preoperative assessment of patients being evaluated for thoracotomy. To routine spirometric testing, the maximal voluntary ventilation should be added. More specific tests do not seem to add predictive information. In addition, individual tests do not seem to correlate with specific complications. The amount of lung resected does not correlate with the occurrence of complications. Patients undergoing lobectomy as opposed to pneumonectomy often experience a stormy postoperative course and are prone to have atelectasis develop and to have an infection in the lung remaining on the operated upon side. Recent data would indicate that this remaining lung tissue is severely compromised during the immediate postoperative period. Those patients who undergo lobectomy may transiently lose considerably more function than would certainly be anticipated from the amount of tissue resected.

A frequency-time domain signal processing system.

A digital signal processing system for time series analysis with two modes of usage--the first a rapid, hands-on exploratory method, and the second an automatic, printed, labeled graphic output method--is described. The system utilizes a Time Data 1923C system with integral PDP-11 minicomputer, and a console. Major error problems have been contained and a large-volume graphic analysis capability has been developed. Applications include (a) transpulmonary pressure-pulse relationships, (b) elucidation of the multiphasic nature of pulmonary-vein/left-atrial-pressure pulse phenomena, (c) suggestive value of transfer function phenomena as a tool to demonstrate the effect of various loading and ischemic phenomena on the left ventricle, and (d) teaching-demonstration of the techniques of digital signal processing.

Thoracoscopy: new method of early diagnosis of cardiac herniation.

Cardiac herniation is an uncommon but rapidly fatal complication of radical pneumonectomy. Although operative correction is simple, a successful clinical outcome requires early diagnosis and thoracotomy. A patient is described in whom a left-sided cardiac herniation through a pericardial defect occurred following radical pneumonectomy. The diagnosis was suspected by persistent hypotension and radiographic changes. Confirmation of the diagnosis was achieved by thoracoscopy, performed with local anesthesia in the operating room. Immediate thoracotomy resulted in a successful outcome.

Apperceptive signals demonstrating the dynamic disturbance of myocardial ischemia.

Analog pressure signals (catheter-tip manometers) from the left atrium, left ventricle, and aorta and a flow signal from the arota were obtained in 25, open-chest, anesthetized dogs in which 115 episodes of ischemia were produced in an area of the left ventricle subtended by the distal left anterior descending coronary artery and its last major diagonal branch. The left ventricular pressure and its first derivative (dP/dt) were displayed as an X-Y loop. The character of this loop went through a unique series of dynamic changes in 110 of the 115 ischemic episodes, indicating that this is a useful tool for monitoring myocardial ischemia. Spectrum pairs of the above signals were analyzed with digital computational transfer functions in 14 ischemic episodes of three experiments and preliminary assessment reveals unique pole and zero changes in many pairs during each episode which also may prove to be a useful indicator of the hemodynamic disturbance incurred during myocardial ischemia.

Intraoperative Doppler coronary artery finder.

Time-consuming difficulty is occasionally encountered in finding coronary arteries or previously placed vascular grafts during coronary revascularization procedures. A catheter-tipped, continuous-wave Doppler ultrasonic probe with simple audio output has been shown to be capable of expediting the search for these vessels.