Mitral valve replacement and repair. Report of 5 patients with systemic lupus erythematosus.

Severe mitral valve regurgitation due to systemic lupus erythematosus is a rare cause of valvular heart disease, necessitating valve surgery. Currently, there are 36 case reports in the world medical literature of mitral valve replacement or repair in patients who have lupus. The current trend in mitral valve surgery is toward anatomic valve repair. In patients who have systemic lupus erythematosus, however, valve repair often leads to repeat surgery and valve replacement. We report the cases of 5 patients with lupus and severe mitral valve regurgitation who underwent mitral valve surgery. In 3 of these patients, replacement with a mechanical prosthetic mitral valve was performed with good long-term results. In the other 2 patients, mitral valve repair was performed, but only 1 of the repairs was successful. The 2nd patient required subsequent replacement with a mechanical valve. To our knowledge, this report of 5 patients is the largest series of mitral valve surgery in patients with lupus. These results, along with a review of the literature, suggest the superiority of mechanical prosthetic valve replacement to repair in patients who have systemic lupus erythematosus.

Positron emission tomographic imaging with fluorodeoxyglucose isefficacious in evaluating malignant pulmonary disease.

OBJECTIVE: Positron emission tomography (PET), when used with the intravenously administered radiopharmaceutical F-18 fluorodeoxyglucose (FDG), has the potential to help in the evaluation of patients with lung cancer because the radiopharmaceutical is concentrated by metabolically active cells. We conducted a retrospective study of PET-FDG in 96 patients evaluated at our institution over the past 2 years for suspected primary pulmonary neoplasms. PET-FDG results were compared with the findings of computed tomographic scans on the same patients. All patients underwent surgical exploration with or without resection of the malignant tumors. Sites of potential malignancy were subjected to biopsy and/or excision, with subsequent pathologic evaluation. RESULTS: A total of 96 patients with suspected or proven primary pulmonary malignant disease were evaluated. Sixty-six patients had histologically confirmed malignant tumors, and 30 had benign masses histologically. PET-FDG had an accuracy of detecting malignancy in pulmonary lesions of 92% (sensitivity 97%; specificity 89%). A total of 111 surgically sampled sites were from lymph nodes. PET-FDG was accurate in predicting the malignancy of nodes in 91% of instances, whereas computed tomography was correct in 64%. The sensitivity, specificity, and predictive accuracy of PET in detecting metastatic lymphadenopathy in mediastinal lymph nodes were 98%, 94%, and 95%, respectively. PET-FDG also changed the M stage in 8 (12%) patients (6 with and 2 without metastases). The 6 malignant (positive) lesions were correctly identified by PET-FDG, and the 2 without tumor were accurately predicted as benign (negative). CONCLUSION: These initial results suggest that PET-FDG is highly accurate in identifying and staging lung cancer. PET-FDG also appears to be more accurate in detecting metastatic mediastinal lymphadenopathy than computed tomographic scan.

Right atrial metastatic melanoma in a patient with transient ischemic attacks.

A 65-year-old-man was admitted for evaluation of a transient ischemic attack. A 4.5 x 5.3-cm right atrial mass and a patent foramen ovale were identified by echocardiography. A 0.5-cm lesion was identified in the left temporal lobe of the brain by magnetic resonance imaging. Positron emission tomography was used to differentiate a tumor from an infarct in the brain. The cardiac and the brain lesions were successfully resected. Histopathologic study of the atrial and cerebral tissue demonstrated that these were metastases from a previously excised scalp desmoplastic malignant melanoma. The patient remains well at 14 months' follow-up.

Partial anomalous pulmonary venous connection to the superior vena cava.

BACKGROUND: Correction of partial anomalous pulmonary venous connection to the superior vena cava (SVC) is often complicated by sinus node dysfunction and occasional pacemaker insertion. METHODS: Between 1964 and 1994 40 patients, ranging from 14 months to 52 years old, underwent an operative approach designed to minimize trauma to the sinus node and its blood supply. The SVC was transected and oversewn above the highest anomalous vein. The anomalous pulmonary veins were redirected across a sinus venosus atrial septal defect (33 patients) or a surgically created atrial septal defect (7 patients) into the left atrium. The atrial septal defect rim was coapted to the intracardiac SVC orifice in 23 patients. An intracardiac baffle was used in 17 patients. The cephalad SVC stump was anastomosed to the right atrial appendage. The origin of the pulmonary veins draining into the SVC was right upper lobe (all patients), right middle lobe (33 patients), and the entire right lung (9 patients). RESULTS: One 31-year-old woman died of severe pulmonary hypertension. An early technical error resulted in one symptomatic SVC obstruction. All patients remained well over follow-up (6 months to 30 years), without residual intracardiac defects. Sick sinus syndrome developed late in only 1 patient (2.5%). No patient has required a pacemaker. CONCLUSIONS: The very low incidence of late arrhythmias with cavoatrial reconstruction is most encouraging.

A comprehensive curriculum for thoracic surgery: survey of opinions from program directors and residents.

BACKGROUND: The Comprehensive Thoracic Surgery Curriculum was developed to provide program directors with a basis for planning instruction and evaluating residents, program practices, and outcomes. A survey design was selected to obtain opinions about the curriculum from a large group of people, ie, all program directors and all active residents. METHODS: Two parallel instruments were developed: one to be completed by program directors and one to be completed by active residents. Responses were collated for directors and residents, entered into a computerized database, and compared using the chi 2 statistic. RESULTS: A response rate of 93% was obtained from the directors and 79% from the residents. The survey demonstrates broad-based support for a comprehensive curriculum by the respondents. Current perceptions of and expectations for the curriculum are diverse and regionalized. Serious concerns are expressed about quality issues and particularly the environment for residency education. CONCLUSIONS: The thoughtful responses of our colleagues will guide leaders who will implement the curriculum for thoracic surgery. Strategies for change will necessarily focus on the prerequisite curriculum.

Biatrial approach to cardiac myxomas: a 30-year clinical experience.

Early surgical intervention for atrial myxomas mitigates morbidity and usually offers cure. The operative approach to resect these tumors is controversial. The purpose of this study was to review our experience with the biatrial approach between 1964 and 1994. The location of the myxoma was left atrium in 17 and right atrium in 3. Mean preoperative New York Heart Association functional classification was 2.7. Surgical approach to the tumor was biatrial in all patients. There were no perioperative strokes, myocardial infarctions, or deaths. Mean follow-up was 7.5 years (range, 2 mo to 27 years) with a postoperative New York Heart Association functional classification of 1.4. One late death occurred, which was unrelated to the myxoma. Advantages of biatrial approach include (1) definition of tumor pedicle by direct visualization, (2) minimal manipulation of the tumor, (3) adequate margins of excision, (4) inspection of all heart chambers, and (5) secure closure of the atrial septal defect. Long-term follow-up demonstrates the efficacy of this operative approach to atrial myxomas.

Preservation of adenosine 5'-triphosphate and mitochondrial function during hypercalcemic reperfusion using verapamil cardioplegia.

Immediate hypercalcemic reperfusion results in ventricular dysfunction and loss of high-energy stores. The purpose of this study was to evaluate the effect of verapamil cardioplegia on the preservation of myocardial energy stores, mitochondrial ultrastructure, and ventricular dysfunction in the postischemic rat heart during immediate hypercalcemic reperfusion. Rats in the control group were subjected to cardioplegia with potassium, while rats in groups 1 to 3 were subjected to the same with verapamil (0.5 mg/L). The control and group 1 rats underwent normocalcemic reperfusion and groups 2 and 3 rats underwent hypercalcemic reperfusion. Myocardial samples were analyzed for adenosine 5'-triphosphate (ATP) content and mitochondrial ultrastructural damage. Hemodynamic parameters of heart rate, aortic flow (AF), and postischemic rate of aortic pressure change (dP/dT) also were evaluated. Data were analyzed using analysis of variance. The ATP stores were preserved at greater than 100% control levels in hearts subjected to verapamil cardioplegia. There was no evidence of irreversible mitochondrial damage. Heart rate, AF, and dP/dT were significantly (p < 0.05) depressed in hearts subjected to verapamil cardioplegia. This study suggests verapamil cardioplegia preserves ATP and mitochondrial function during immediate hypercalcemic reperfusion but does not improve postischemic hemodynamics.

Repair of thoracoabdominal ectopia cordis with myocutaneous flaps and intraoperative tissue expansion.

Thoracoabdominal ectopia cordis is a congenital malposition of the heart and abdominal viscera, which are externally situated, carrying an extremely poor prognosis. We report a case of a complete thoracoabdominal ectopia cordis that had undergone successful coverage over the exposed heart and abdominal contents. A few hours after birth, the defect was repaired with an expanded polytetrafluoroethylene soft-tissue patch that was gradually reduced by suture plication. Coverage was completed 48 hours later with bilateral pectoralis major and rectus abdominis myocutaneous flaps. Intraoperative tissue expansion minimized the cardiac compression produced by surgical reconstruction of the defect. Our patient, who is now 36 months old, represents the seventeenth case to survive reconstructive attempts.

Technique for management of an axilloaxillary by-pass graft complicating a median sternotomy.

A technique is presented for intraoperative management of an axilloaxillary by-pass graft when performing a median sternotomy for myocardial revascularization. This method allows continual perfusion of both upper extremities during the operation thereby preventing the potential complications of upper extremity or cerebral ischemia.

Complex reconstruction of the chest wall and breast utilizing a customized silicone implant.

The correction of chest wall anomalies with Poland's syndrome may require a variety of surgical options, depending on the severity of the deformities presenting in a given patient. In difficult cases a customized silicone breast and chest wall prostheses may be used as an alternative method to reconstruct both structures.

Safe use of heparin-coated bypass circuits incorporating a pump-oxygenator.

Durable, covalently bonded, heparin-coated cardiopulmonary bypass (CPB) circuits with oxygenators have been developed. Proposed advantages of heparin-coated CPB circuits include improved biocompatibility and thromboresistance. The purpose of this study was to evaluate our experience with heparin-coated CPB circuits in 20 patients. Heparin was given to maintain an activated clotting time equal to or greater than 200 seconds, while flow rates were kept equal to or greater than 2 L/min. Indications for use of this circuit included recent stroke, posttraumatic injuries, recent gastrointestinal bleeding, protamine allergies, combined cardiac and noncardiac procedures, and ventricular assist. Mean heparin dosage was 0.50 +/- 0.18 mg/kg and protamine dosage was 57.14 +/- 39.36 mg. Postoperative blood loss and transfusion requirements were minimal. Postoperative complement levels of C3a and C5a were normal, suggesting excellent biocompatibility. There were no deaths or perioperative complications. Heparin-coated CPB circuits using a pump oxygenator can be used safely with low-dose heparin administration in select patients requiring CPB.

Potential application of p53 as an intermediate biomarker in Barrett's esophagus.

Diagnosis of the neoplastic progression in Barrett's esophagus using the histologic classification of dysplasia is frequently difficult. The tumor suppressor protein p53, when mutated, confers a promoter effect on cell growth. The purpose of this study was to evaluate the applicability of p53 as an intermediate biomarker of malignancy in Barrett's esophagus. Archival analysis of 100 biopsy specimens of Barrett's esophagus and 10 esophageal adenocarcinomas were compared with 35 chronic esophagitis biopsy specimens. Immunocytochemistry using an anti-p53 monoclonal antibody was performed and elevated immunoreactivity quantitated microscopically. Data were analyzed using a logistic regression model. Significant p53 immunoreactivity occurred as follows: chronic esophagitis (0%), Barrett's esophagus without dysplasia (10%), with low-grade dysplasia (60%), with high-grade dysplasia (100%), and adenocarcinoma (70%). All cases of Barrett's esophagus were significantly immunoreactive when compared with the chronic esophagitis cases (p = 0.001). There was an increase in p53 immunoreactivity as the histologic classification progressed toward adenocarcinoma (p = 0.001). Progression to high-grade dysplasia may be predicted based on p53 immunoreactivity. These findings suggest a role for p53 as an intermediate biomarker in Barrett's esophagus.

Current management of esophageal impactions.

We analyzed our experience at a university medical center from 1977 to 1990 to assess our success in using esophagoscopy and related treatments for removing esophageal impactions. There were 157 episodes of impaction in 150 patients, consisting of 39 pediatric and 111 adult patients. In the pediatric cases, foreign bodies were most often the cause of impaction, while adult cases were usually caused by food or bones. Esophagoscopy was performed successfully in 32 of 34 pediatric patients in which it was attempted; there was only one complication. Other forms of therapy that were infrequently tried met with variable results. Esophagoscopy was successful in removing the impaction in 104 of 109 attempts in adults. Two perforations occurred, with one resulting in death. Various other methods achieved success in the remaining patients. The data suggest that esophageal impaction can be treated successfully by endoscopy with very low morbidity and mortality.

Use of heparin-coated cardiopulmonary bypass.

A 49-year-old man with unstable angina and a history of severe anaphylaxis to seafood and intravenous iodine needed myocardial revascularization. Because of concern of an intraoperative protamine reaction, preoperative treatment was instituted with steroids and with H1 and H2 blockers. Revascularization was accomplished using a heparin-coated cardiopulmonary bypass circuit. Complement activation and postoperative bleeding were minimal. Heparin-coated cardiopulmonary bypass is a safe, effective technique of bypass in select patients.

Effects of insufflation on hemodynamics during thoracoscopy.

Thoracic procedures once requiring open thoracotomy are now being performed with video-assisted thoracoscopy. To visualize adequately the intrathoracic structures, creation of an artificial pneumothorax by carbon dioxide insufflation under positive pressures has been advocated. We hypothesized that positive-pressure insufflation during thorascopy would cause significant hemodynamic compromise. Eight healthy female pigs underwent general endotracheal anesthesia and placement of monitoring lines. After placement of a thorascope, baseline hemodynamic measurements were obtained at 0 mm Hg (atmospheric pressure). Measurements were taken randomly at 5, 10, and 15 mm Hg using carbon dioxide insufflation after stabilization at each pressure. Data were analyzed using Page's test for noparametric variables. Insufflation pressures of 5 mm Hg or greater resulted in significant decreases in cardiac index, mean arterial pressure, stroke volume, and left ventricular stroke work index, whereas central venous pressure increased (p < 0.001). Changes in heart rate were not significant. We do not recommend routine positive-pressure insufflation during thorascopy because of the significant hemodynamic compromise in our experimental model.

Unusual location of an atrial myxoma complicated by a secundum atrial septal defect.

Myxomas occur most commonly in the left atrium arising from the fossa ovalis. We report the case of a left atrial myxoma originating from the base of the right inferior pulmonary vein. This large myxoma filled a large secundum atrial septal defect, which was diagnosed intraoperatively. The unusual position of this myxoma and operative management of the associated atrial septal defect are discussed.

Myocardial performance after contusion with concurrent hypovolemia.

Myocardial contusion may present as a benign nonclinical event or a life-threatening emergency. Although cardiac output is recognized to be decreased with major contusion, the contribution of hypovolemic shock to myocardial dysfunction is unclear. This study was designed to evaluate the relationship between myocardial contusion and hypovolemic shock. After Sprague-Dawley rats were anesthetized, contusions were administered at either 80 psi or 120 psi. Half of each group then underwent hypovolemic shock. After 24 hours of recovery, cardiac hemodynamics were studied in each subgroup using the Neely-Langendorff apparatus. Isoenzymes and histology were evaluated as well. The data showed that rats undergoing hypovolemic shock in each subgroup had a significant decrease in cardiac output when compared with their controls. This decrease was more pronounced in the 120-psi group. Cardiac isoenzyme levels were elevated in all groups. Microscopic evaluations showed contusion in the controls and necrosis in the shock groups. Patients whose injuries are compatible with myocardial contusion and hypovolemic shock should be resuscitated quickly and evaluated for myocardial dysfunction secondary to infarction.