The long-term outlook for valve replacement in active endocarditis.

This study follows the clinical course of 22 patients in the active phase of infective endocarditis who inderwent valve replacement at North Carolina Memorial Hospital between March, 1966, and March, 1976. At the time of operation, there was gross valve tissue destruction in 16 patients, verrucae in nine, ruptured chordae tendineae in five, and myocardial or annular abscess formation in five. Four patients survived less than 6 months after the initial operation. One survived almost 3 years before dying of recurrent carcinoma of the lung. The remaining 17 patients have been followed an average of 4.6 years. Major postoperative complications were as follows: paravalvular problem, five patients; congestive heart failure, seven patients; complete heart block, three patients; systemic arterial emboli, four patients. These complications often were associated with the preoperative presence of annular or myocardial abscess. Thus it appears that postoperative complications often result from annular structural deficiencies rather than being directly related to active infection.

Hemodynamic evaluation of the Lillehei-Kaster pivoting disc valve in patients.

Forty-five patients with Lillehei-Kaster pivoting disc valves had intraoperative assessment of valve hemodynamic function by simultaneous recording of aortic, left ventricular, and left atrial pressures and cardiac output. Mean transvalve gradients and prosthetic valve areas were calculated and recorded. Comparison of the results with data previously reported on the caged-ball valves indicates that the Lillehei-Kaster pivoting disc valve has superior hemodynamic characteristics.

Immobilization of disc heart valves by unraveled sutures.

Disc immobilization by a prolapsed suture end was observed in a laboratory animal with a pivoting disc heart valve. An identical occurrence was experienced in a clinical situation by other investigators. These experiences prompted a review of sutures and suturing techniques in implanting disc heart valves, in an effort to ascertain the vulnerability of all disc valves toward disc immobilization by sutures. An attempt was made to immobilize the discs in five currently available heart disc valves with prolapsed sutures under various handling conditions. Variables included the model of disc valve, the location of the prolapsed suture, and the type of suture material used. Our investigation showed that any of the valves studied can be immobilized by prolapsed sutures. However, this complication is avoidable if the implanting surgeon adheres to a few precautionary suturing principles.

The assessment of operability of esophageal carcinoma.

The extremely poor outlook for patients with esophageal cancer necessitates careful definition of the extent of disease prior to the selection of treatment. Evaluation of regional lymph node involvement may avoid excessive morbidity and identify favorable candidates for aggressive excisional therapy. The role of combined mediastinoscopy and celiotomy in assessing the operability of epidermoid carcinoma of the thoracic esophagus was examined in 30 consecutive candidates for esophageal resection at the North Carolina Memorial Hospital. The prognostic value of combined mediastinoscopy and celiotomy in assessing the operability of epidermoid value in assessing mediastinal extension of carcinoma of the upper thoracic and midthoracic esophagus.

Selective application of fundoplication in achalasia.

Although esophagomyotomy alone may effectively relieve dysphagia in patients with achalasia, utilization of a complementary fundoplication procedure should be considered for selected patients. Fundoplication is a sensible addition to myotomy in circumstances that suggest high risk for the development of reflux esophagitis. Also, in complicated achalasia, relief of esophageal obstruction by simple myotomy may not be achieved safely. Identification of those pathological features associated with achalasia that merit consideration of fundoplication should improve operative results and reduce morbidity. This paper examines the application of a complementary fundoplication procedure in the operative management of 21 patients with achalasia over a ten-year period.

Surgical management of symptomatic pulmonary aspergilloma.

Pulmonary aspergilloma is a potentially life-threatening disease resulting from the colonization of lung cavities by the ubiquitous fungus Aspergillus fumigatus. Complex aspergilloma, characterized by thick-walled cavities with surrounding parenchymal inflammation, is a risk factor for increased morbidity and mortality. Fifteen patients with symptomatic aspergilloma underwent major thoracic procedures at North Carolina Memorial Hospital between January 1, 1972, and December 31, 1983. Twelve of the patients had hemoptysis; in 7 it was recurrent and in 5, life threatening. Tuberculosis and sarcoidosis were the most common underlying causes of lung disease, and more than half of the patients had other coexistent serious medical illness. Eleven of the 15 patients were seen with complex aspergilloma; all of the 4 major complications and the 2 deaths occurred in these patients. Bronchopleural fistula with persistent air space was the most common serious complication, and required thoracoplasty in 3 patients. Nine patients, including 5 with complex aspergilloma, had no postoperative complications, and there were no recurrent symptoms in any of the 13 operative survivors over a mean follow-up of five years. It is concluded that aggressive pulmonary resection can provide effective long-term palliation in critically ill patients with symptomatic pulmonary aspergilloma.

Conjoined subrectus pocket for permanent pacemaker placement in the neonate.

We present a method of pacemaker implantation in neonates using a subxyphoid epicardial lead and subrectus placement of the pulse generator. This method is simple and safe and carries minimal morbidity.

Correlation of preoperative pulmonary function testing with clinical course in patients after pneumonectomy.

Postoperative morbidity and mortality were correlated with the preoperative results of three widely used tests of pulmonary function in 90 patients who underwent pneumonectomy for carcinoma of the lung. Factors analyzed following operation included thirty-day mortality, the incidence of arrhythmias, the frequency of respiratory complications, and the number of individuals requiring prolonged mechanical ventilation. Fourteen patients had a forced vital capacity (FVC) of 70% or less of predicted normal value. Eleven had a one-second forced expiratory volume (FEV1) of 1.5 liters or less, and 32 had an FEV1 of less than 2 liters. Twenty-six had an FEV1/FVC ratio of 0.6 or less. There were no differences in morbidity or mortality between these individuals and the patients whose test scores exceeded these criteria. As a general rule, decisions regarding operability and extent of resection cannot be made solely on the basis of the three spirometry tests reviewed.

The role of transbronchial lung biopsy in diffuse pulmonary disease.

Forty consecutive patients underwent flexible fiberoptic transbronchial lung biopsy for diagnosis of diffuse nodular or infiltrative lung disease. Biplane fluoroscopic examination with image intensification greatly facilitated accurate placement of the biopsy forceps near the pleura; Specimens of lung parenchyma were obtained for culture and histological study in every case. A pathological diagnosis was correctly established in 34 of 40 patients. Transbronchial biopsy was helpful in the clinical management of an additional 4 patients. Biopsy results were not accurate in 2 patients. No significant morbidity was associated with the procedure. Fiberoptic transbronchial lung biopsy is a safe and useful adjunct to the diagnosis of parenchymal lung disease.

Clinical evaluation of the Lillehei-Kaster pivoting-disc valve.

A four-year clinical evaluation of 133 patients with Lillehei-Kaster pivoting-disc valves has shown that patients with an aortic valve prosthesis have remained free from valve-related problems. Patients with a mitral valve implanted have a satisfactory survival record as calculated by actuarial methods; however, a 10% incidence of valve thrombosis was experienced. Analysis suggests that this may be related to inadequate anticoagulation or use of an inappropriate suturing technique or both. The patients enjoyed significant clinical improvement following operation, with no evidence of hemolysis. A history suggestive of postoperative embolization was present in only 1 patient in this series.

Major pulmonary resection for suspected but unconfirmed malignancy.

Thoracotomy is not infrequently performed in patients with suspected pulmonary carcinoma but with no histological or cytological confirmation of malignancy. The intraoperative decision to proceed with major pulmonary resection (lobectomy or pneumonectomy) is difficult if a large or central lesion precludes total excisional biopsy. Incisional or needle biopsies violate the principles of good cancer surgery, and the results may be inconclusive if the tumor is missed and areas of associated inflammation or necrosis are sampled. Between January 1, 1970, and December 31, 1980, 303 patients underwent thoracotomy for suspected but unconfirmed malignancy. One hundred twenty-two had a minor resection only, 79 had a major resection (lobectomy or pneumonectomy) after a diagnosis was established by frozen section, and 102 had a major resection without a definitive diagnosis of cancer. Carcinoma subsequently was found in 68% (69) of this group of 102 patients, and benign lesions were identified in the remaining 32% (33), all of whom underwent lobectomy. The diagnoses in these 33 patients included seven granulomas, three hamartomas, nine instances of tuberculosis, and fourteen instances of fibrosis, inflammation, or cystic degeneration. The 2 thirty-day operative deaths in this group of 102 patients occurred among the 69 with malignant disease; 1 died of hemorrhage following pneumonectomy and 1, of respiratory insufficiency after lobectomy. In all 303 patients, there was no difference in operative mortality (p less than 0.01) between lobectomy (2%) and a lesser resection (1.6%). In a patient with a suspicious but inaccessible pulmonary lesion, lobectomy can be performed safely without violating the principles of cancer surgery. This recommendation should probably not be extended to lesions requiring pneumonectomy, because of the increased rates of morbidity and mortality associated with that procedure.

Esophagogastrectomy as palliative treatment for esophageal carcinoma: results obtained in the setting of a thoracic surgery residency program.

The palliative treatment of esophageal carcinoma has included intubation, bypass, dilation, irradiation, and esophagogastrectomy. The last has been criticized by some on the basis of high operative morbidity and mortality. To assess the success of this method at our institution, we reviewed the 60 consecutive resections performed for carcinoma of the esophagus from January, 1972, through June, 1983. Forty-six patients had squamous cell tumors and 14, adenocarcinomas. There were 47 men and 13 women, and the mean age was 59.9 years (range, 38.5 to 78.9 years). The most frequent preoperative findings included dysphagia (55), weight loss (34), chest pain (22), and vomiting (49). Fifty (83%) out of the 60 resections were performed by the resident staff under the supervision of an attending surgeon. Four patients died within 30 days of operation, an operative mortality of 6.7%. Immediate causes of death included respiratory failure, myocardial infarction, hemorrhage, and renal failure. One of the patients who died and 3 of the survivors had an anastomotic leak. There were 27 additional complications in 24 patients: respiratory problems (8), arrhythmias (5), pleural effusion (4), gastric outlet obstruction (2), wound infection (2), and 1 each of pulmonary embolus, acute brain syndrome, congestive heart failure, myocardial infarction, chylothorax, and empyema. The one-, two-, three-, and five-year actuarial survival rates were 46%, 27%, 10%, and 5%, respectively. Mean survival for the 46 patients dead at the time of this study was 13.5 months. Outpatient follow-up data were available on 53 (95%) of the operative survivors and showed an absence of dysphagia in 87.5% during most of the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)

Elective pulmonary lobectomy: factors associated with morbidity and operative mortality.

Periodic review of clinical results is essential to ensure that high-quality patient care is maintained. To that end, we reviewed the morbidity and operative mortality in a consecutive series of 369 pulmonary lobectomies performed between January 1, 1970, and December 31, 1983. There were 251 male and 118 female patients with a mean age of 50.6 years. The thirty-day operative mortality was 2.2% (8/369), with 6 of these deaths related primarily to respiratory insufficiency. Two hundred twenty-four postoperative management problems occurred in 151 patients and included arrhythmia, air leak, pneumothorax, respiratory difficulties, postoperative bleeding, pleural effusion, wound infection, myocardial infarction, pulmonary embolus, empyema, bronchial stump leak, and lobar gangrene. Multiple factors were related to the occurrence of postoperative morbidity and mortality using both chi-square analysis to examine each individual item and discriminant analysis to evaluate their interaction. Chi-square tabulation showed no difference in the occurrence of major postoperative complications (p greater than 0.05) related to the side of operation, an abnormal preoperative electrocardiogram, a forced vital capacity of 2.8 liters or less, a one-second forced expiratory volume (FEV1) of less than 1.7 liters, an oxygen tension of less than 60 mm Hg, or the seniority of the surgeon (resident versus attending). An increased number of complications (p less than 0.05) was found in male patients, in patients operated on for carcinoma, and in patients older than 60 years. Stepwise discriminant analysis included FEV1 as a significant predictor of postoperative complications.(ABSTRACT TRUNCATED AT 250 WORDS)

A clinical review of patients undergoing resection for pulmonary hamartoma.

Both the radiology and surgery literature mention "popcorn calcification" as a diagnostic aid in identifying pulmonary hamartomas. Nineteen patients underwent resection of pulmonary hamartomas at North Carolina Memorial Hospital between January 1969 and February 1983, representing 1.9 per cent of all thoracotomies performed for pulmonary disease. Of the 19 patients, there were 12 men (63%) and 7 women (37%), and most were asymptomatic. Chest x-ray demonstrated 12 right-sided and 7 left-sided lesions. All masses were located peripherally in the lung parenchyma and in no instance was calcification present. Fourteen wedge resections and 5 lobectomies were performed. Pathologic examination confirmed the absence of calcification; however, in two cases (11%) an associated malignancy was present. There were no operative deaths and only minor postoperative complications. All problems resolved without difficulty. These data show that pulmonary hamartomas are not commonly associated with calcification, and there may be an increased association with carcinoma of the lung. Excision can be performed with minimal morbidity and is necessary to distinguish hamartomas from malignant lesions.

Ventricular tachycardia and ventricular aneurysm due to unrecognized sarcoidosis.

Cardiac involvement due to sarcoidosis is well recognized. Arrhythmias have been recognized in up to 50% of patients who have cardiac involvement. We report on two patients with no systemic manifestations of sarcoidosis who presented with refractory ventricular tachycardia. Evaluation demonstrated atypical left ventricular "aneurysms" with normal coronary arteries. Surgical pathology demonstrated granulomas consistent with sarcoidosis. Despite extensive surgical resection, they continued to have symptomatic ventricular tachycardia requiring implantation of a defibrillator. Recognition of sarcoidosis as an etiology for ventricular tachycardia and aneurysm is important for possible avoidance of surgery.