Percutaneous transluminal angioplasty of congenital coarctation of the aorta.

Two cases of successful dilatation of congenital coarctation of the aorta using the Grüntzig technique are reported. In a 3-week-old boy and an 11-month-old girl, systolic gradients across the narrowed areas were lowered from 50 to 8 mm Hg and from 23 to 8 mm Hg. Although the femoral pulses later disappeared in the younger patient, surgery was avoided. The second patient's gradient has remained minimal for 8 months and no surgery has been performed.

Management of trachea--innominate artery fistula.

The case histories of three patients with trachea-innominate artery fistula are presented. Low tracheostomy was the etiologic factor producing the fistula in two patients. In both cases, the neck was hyperextended by placing a large roll behind the patient's shoulders and thereby elevating the trachea out of the mediastinum. In one patient a balloon cuff eroded the innominate artery. Management of these patients includes control of hemorrhage by cuff overinflation and/or by endotracheal intubation and packing of the tracheostomy site. The best surgical approach is via a right anterior thoracotomy and a separate neck incision to isolate the blood vessels involved. Median sternotomy should be avoided to prevent mediastinal infection and sternal dehiscence. Carotid stump pressures are a useful guide to determine the efficacy of innominate artery ligation. One patient was saved and is a long-term survivor.

Mortality prediction in adult respiratory insufficiency.

The results of treatment of acute respiratory insufficiency in the adult must be quantitated before indications for innovative treatment (such as extracorporeal oxygenation) can be defined. A method for retrospective and prospective data collection based on a graph of A-a gradient and time was evaluated in 45 patients. From this graph a pulmonary insufficiency index (PII) can be calculated which correlates well with mortality in this series. The mean PII of surviving patients was 0.84 and the highest value was 2.75. The mean PII of patients who died with pulmonary insufficiency was 15.9; the lowest value was 6.0. Using this method with a larger data base, it will be possible to predict mortality based on PII facilitating the study of ongoing management and innovative treatment methods.

Arterial prosthesis of microporous expanded polytetrafluoroethylene for construction of aorta-pulmonary shunts.

A new arterial prosthesis made of polytetrafluoroethylene (OTFE) was evaluated in 10 infants with complex cyanotic congenital heart disease. All grafts used were 4 mm. in diameter and varied in length from 0.8 to 6 cm. The grafts were anastomosed to the main pulmonary artery or its bifurcation in 8 infants and to the right and left pulmonary arteries in one each. There were two early deaths, one of which was related to shunt failure. The advantages of a shunt to the main pulmonary artery are obvious, and the intraoperative procedure is facilitated with the prosthesis. Follow-up averages 9 months in the 8 survivors, and the patients have nearly doubled their preoperative weight. A shunt murmur is present in each case and the children have mild-to-moderate cyanosis at rest. Repeat aortograms in 2 patients, 8 and 10 months postoperatively, show a smooth graft without luminal narrowing. The aortic oxygen saturations were 73 per cent. The PTFE graft and/or anastomoses will not grow with the growth of the child and therefore may not accommodate growth by increased flow. This may prove to be a limiting factor in its long-term use in fants. We reserve the use of these grafts for infants with complex cyanotic defects undergoing emergency surgery or in older children in whom a conventional shunt is not possible or a previous shunt has failed.

Extracorporeal membrane oxygenator support for cardiopulmonary failure. Experience in 28 cases.

We have used extracorporeal membrane oxygenation (ECMO) for 28 patients (14 children and 14 adults) over a 5 year period. Nine patients improved on ECMO and 5 were long-term survivors. ECMO was used for pulmonary insufficiency in 24 patients. Initially, only moribund patients were treated, but recently the combination of open lung biopsy and pulmonary insufficiency index (PII) has been used to select patients. The best results have been obtained in newborn cases and the adult capillary leak syndromes; the major problem has been progression to fibrosis despite ECMO support. ECMO was used for cardiac failure in 4 patients. Children with postoperative cardiac failure did the best; profound shock was not reversed with venoarterial bypass. ECMO support is lifesaving in selected cases of pulmonary insufficiency. Initial trials in cardiac failure and the infant age group in this series suggest that ECMO will have an even greater role in those applications.

Extracorporeal circulation (ECMO) in neonatal respiratory failure.

Sixteen moribund newborn infants with respiratory failure were treated with extracorporeal membrane oxygenation (ECMO) for 1 to 8 days. Cannulation via the right jugular vein and carotid artery was used to establish venoarterial-cardiopulmonary bypass. High flow (80 percent of cardiac output) allowed decreasing FIO2 and airway pressure. Diagnoses and results were as follows: respiratory distress syndrome, four patients (two improved, one survived); meconium aspiration syndrome, eight patients (four improved, three survived); persistent fetal circulation (some with diaphragmatic hernia), four patients (three improved, two survived). Intracranial bleeding occurred in 43 percent, accounting for most of the deaths. In a parallel series of 21 infants treated with conventional ventilator therapy, the mortality rate was 90 percent and intracranial bleeding occurred in 57 percent. ECMO provided life support and gains time in newborn respiratory failure. In high mortality risk infants, the rate of survival is higher and intracranial bleeding lower with ECMO than with optimal ventilator management.

Extracorporeal membrane oxygenation for newborn respiratory failure: forty-five cases.

Almost all types of newborn respiratory failure are reversible. However, supportive treatment (oxygen and positive airway pressure) can damage the lung, and newborn respiratory failure remains a major cause of morbidity and death in infants. Prolonged extracorporeal membrane oxygenation (ECMO) provides life support while allowing the lung to "rest." We have used ECMO in 45 moribund newborn infants; 25 survived. Neonatologists referred patients who were unresponsive to maximal therapy. The right atrium and aortic arch were cannulated via the jugular vein and carotid artery. Heparin was infused continuously to main activated clotting time at 200 to 300 seconds. Airway oxygenation and pressure were reduced to low levels. Primary diagnoses were hyaline membrane disease, 14 (6 survived, 8 died); meconium aspiration, 22 (15 survived, 7 died); persistent fetal circulation including diaphragmatic hernia, 5 (3 survived, 2 died); and sepsis, 4 (1 survived, 3 died). Growth, development, and brain and lung function are normal in 20 of 25 survivors. ECMO decreased newborn respiratory failure mortality and morbidity rates in this phase I trial. A controlled randomized study is underway. The results suggest that ECMO may be effective in older patients if used before irreversible lung damage occurs.

Impact of regionalization. The Orange County experience.

Prior to the designation of a trauma system in Orange County, Calif, 73% of the in-hospital non-CNS deaths secondary to motor vehicular trauma were judged by the autopsy method to have been preventable. In June 1980, a regional system of trauma care with designated trauma centers was established in Orange County. We used the autopsy method to evaluate the first year's experience with this new system and compared the results with previous studies in Orange County for 1974, San Francisco County in 1974, and Orange County in 1978-1979. The results indicate a severe reduction in the number of deaths judged preventable. In addition, a more aggressive approach to the traumatized patient was noted as indicated by an increased percentage of patients who received appropriate surgical intervention.

Subclavian artery patch angioplasty. Treatment of infants and young children with aorta coarctation.

Repair of thoracic aorta coarctation in infants has had a high recurrence rate in most series. Recurrence is the result of several factors, but the type and growth of anastomosis are of primary importance. Subclavian artery patch angioplasty was used consecutively in eight children under the age of 5 years. There are six long-term survivors who have been observed for an average of 22 months. Body surface area during this time increased from a mean of 0.22 sq m preoperatively to a mean of 0.54 sq m at present. Blood pressure in the arms and legs were recorded at recent examination using an ultrasound pressure recorder. Only one patient had a substantial gradient (30 mm Hg). All survivors are asymptomatic. Use of the subclavian artery appears to allow for growth at the repair site.

Endogenous caloric sources and nitrogen balance: regulation in postoperative patients.

Twenty-three postoperative patients were divided into three groups to evaluate the peripheral vein administration of solutions containing glucose, amino acids, or glucose and amino acids. Serum insulin, glucose, and nitrogen balances were monitored in each patient. Serum insulin concentrations rose on the first postoperative day in all three groups, then fell to near preoperative levels by the third day after surgery. Negative nitrogen balance was most pronounced in patients recieving glucose only. Patients receiving only amino acids had a reduction in nitrogen balance, but some protein catabolism was present. The mean nitrogen balance in patients who received a combination of these solutions was positive on days one and two after surgery and slightly negative on the third postoperative day. These changes were not significantly better than the amino acid group. However, the combination group had 12 to 21 days of positive balance, as compared to seven of 20 days in the amino acid group. Since starvation adaptation accurs gradually, it is concluded that the simplest and safest way to reduce protein catabolism in the immediate postoperative period is by the peripheral intravenous administration of both glucose and amino acids.

Prevention of peritoneal adhesions in the rat. The effects of dexamethasone, methylprednisolone, promethazine, and human fibrinolysin.

Peritoneal adhesions were created in rats by brisk scrubbing of the terminal part of the ileum. Adhesions were graded by total number and the presence of small bowel obstruction. Adhesion prophylaxis was evaluated using dexamethasone, methylprednisolone sodium succinate, promethazine hydrochloride, and human fibrinolysin (Thrombolysin) in various combinations, doses, and routes of administration. Methylprednisolone and dexamethasone, depending on the route of administration, modified the total number of adhesions but did not modify their severity when compared to control animals. Promethazine by itself modified peritoneal adhesions in the rat. Used together, methylprednisolone and promethazine also modified adhesions, but were not substantially better than the combination of dexamethasone and promethazine. Methylprednisolone, promethazine, and human fibrinolyzin, when used in combination intraperitoneally, virtually eliminated adhesion formation.

Rupture of the thoracic aorta following blung trauma.

Six patients underwent emergency surgery for descending aortic injury following blunt trauma to the chest; three survived. Associated injury was a critical factor in two of the three patients who died. In the third patient, prolonged ischemia of the lower half of the body due to total aortic distraction with a distal aortic flap produced irreversible changes that were manifest during reperfusion of the body. Angiography is recommended if the patient's condition is stable and other injuries demanding immediate surgical attention are not present. If, however, there are other serious injuries and adequate distal perfusion, then these other injuries should be corrected before aortic repair is undertaken.

Surgical treatment of infective valvular endocarditis.

Infective valvular endocarditis, whether occurring on a native or prosthetic heart valve, continues to carry a serious prognosis. Death is usually due to congestive heart failure, arrhythmia, or embolic complications, rather than infection per se. While antimicrobial therapy and medications to control congestive heart failure continue to be the treatment of choice in most cases, early valve replacement is indicated in certain situations. During the past four years, 12 patients underwent valve replacement for infective endocarditis. Six patients underwent elective valve replacement after antibiotic or antifugal therapy. All survived the operation and were improved. Six other patients underwent emergency valve replacement. Two patients died intraoperatively and their operations, in retrospect, were delayed unnecessarily. Four patients survived and are improved. Prosthetic valve replacement during the course of infective valvular endocarditis should be considered based on indications such as congestive heart failure, rhythm disturbances, etc, rather than the status of the infection.

Growth changes in the thoracic aorta of the piglet following patch angioplasty.

Patch repair of the thoracic aorta using prosthetic graft material in neonates and infants has been advocated, but long-term results have not confirmed that the residual aorta grows. In this study five piglets had portions of aortic tissue excised, ranging from 38% to 72% of the aortic wall. Each pig underwent patch angioplasty repair of the thoracic aorta with prosthetic graft material. Piglets achieved full growth at approximately six months. Aortic catheterization and contrast angiography were done in each animal before it was killed. Growth and histologic study of the aorta was documented at postmortem examination. There were no blood pressure gradients at rest or with isoproterenol hydrochloride (Isuprel)-epinephrine challenge in four of the five piglets. In one animal that underwent a 72% resection of the aortic circumference, a 20-mm gradient was present at rest. It was concluded that the thoracic aorta in piglets will grow adequately to allow patch grafting of up to 70% of the aortic circumference.

Nitrogen balance in adult hospitalized patients with the use of a pediatric amino acid model.

Normalization of plasma amino acid patterns and that relationship to improved nitrogen balance was studied using a pediatric-specific amino acid solution in 21 adults requiring total parenteral nutrition therapy. There was a significantly positive correlation between improved nitrogen balance and the amino acids cystine, tyrosine, total cysteine/cystine, and ornithine. When additional cysteine was added to the solution of 11 subjects, taurine also correlated with nitrogen balance. Despite higher amounts of histidine in solution, plasma amino acid levels were not normalized. These amino acids, heretofore considered nonessential, may be required in specific molar ratios in stress. The use of a 30% branched-chain pediatric-balanced amino acid solution resulted in near normalization of plasma amino acid levels and group mean positive nitrogen balance.

Substernal thoracoscopic guidance during sternal reentry.

Reentry sternotomy is commonplace, as more patients are returning for second, third, or more repeat cardiac procedures. Catastrophic hemorrhage remains the most dreaded complication during reentry and carries a significant morbidity and mortality. Although various methods are used to reduce the risk of hemorrhage, we have found that substernal thoracoscopy is preferable. Our experience with this technique in both adults and children is presented.

Surgical treatment of primary sternal osteomyelitis.

Four patients with primary sternal osteomyelitis are described. Pseudomonas aeruginosa was the infective organism. Three of the 4 were heroin addicts. Limited surgical resection with preservation of the posterior periodteum is recommended for an infected sternum. Postoperative antibiotic therapy for a period of six weeks is also recommended. Preservation of the posterior sternal periosteum rather than conventional radical excision is important for maintaining physical stability and avoiding chest wall deformity in the group of patients.

Primary sternal osteomyelitis.

A case report of primary sternal osteomyelitis, a rare clinical entity, is presented. Treatment of primary sternal osteomyelitis is antibiotics and complete debridement of the infected bone and anterior periosteum. If the posterior sternal periosteum is not involved, it should be left intact. The defect can be covered with skeletal muscle flaps, which improves healing and minimizes recurrence. This approach led to a complete and timely cure.

Reduction pneumonoplasty for patients with a forced expiratory volume in 1 second of 500 milliliters or less.

BACKGROUND: Patients with severely impaired pulmonary function are considered at high risk for emphysema operations. We prospectively evaluated 44 patients with a forced expiratory volume in 1 second of 0.5 L or less undergoing reduction pneumonoplasty for dyspnea uncontrolled by medical management (confirmed by Borg and modified Medical Research Council dyspnea scales). METHODS: There were 28 men and 16 women (mean age, 66 years) with a mean preoperative forced expiratory volume in 1 second of 0.41 L (range, 0.23 L to 0.50 L). Preoperative therapy consisted of bronchodilators (100% of patients), oxygen (80%), and steroids (72%). Hypercarbia was seen in 80% of patients, and 66% had pulmonary hypertension. Unilateral reduction pneumonoplasty by a video-assisted thoracic surgical approach was performed in 34 patients, 6 patients underwent bilateral reduction pneumonoplasty by a video-assisted thoracic surgical approach, and 4 patients underwent bilateral reduction pneumonoplasty by a video-assisted thoracic surgical approach, and 4 patients underwent bilateral reduction pneumonoplasty by median sternotomy. Discrete emphysematous regions were resected using staplers with buttressing, and regions of homogeneous emphysema were plicated with KTP or neodymium:yttrium-aluminum garnet laser radiation. RESULTS: There was one death within 30 days, two additional deaths within 60 days, and five additional deaths within 1 year. Hospital stay averaged 12 days. Intensive care unit stay averaged 4 days. Subjective improvement was noted by 89%. Borg and modified dyspnea scores improved from 7.6 to 4.5 (p < 0.01) and from 3.9 to 2.35 (p < 0.01), respectively. Forced expiratory volume in 1 second was 0.62 L at 1 year, a 51% improvement (p < 0.001). Forced vital capacity was 1.32 L preoperatively and 2.05 L at 1 year (a 56% improvement) (p < 0.001). CONCLUSIONS: This experience documents that patients with severely impaired lung function can successfully undergo operation for emphysema. To obtain these results one must tailor the operative approach to the patient's disease.

Ventriculotomy repair during revascularization of intracavitary anterior descending coronary arteries.

Optimal revascularization of the rare variant anomolous intracavitary left anterior descending coronary artery requires, by definition, entrance into the right ventricular cavity. We present a simple method to repair the ventriculotomy without risk of obliterating the left anterior descending coronary artery, septal perforators, or diagonal branches.