Intraoperative measurement of adrenocorticotropin (ACTH) during removal of ACTH-secreting bronchial carcinoid tumors.

The optimal treatment for ectopic ACTH syndrome is the complete removal of the tumor secreting ACTH. These tumors are often occult, with their location suggested but not proven with imaging techniques. The intraoperative measurement of ACTH by immunoradiometric assay in five patients with the occult ectopic ACTH syndrome during removal of suspicious intrapulmonary lesions is reported. A significant ACTH gradient was detected in the pulmonary veins of the affected lobes in two patients. ACTH had decreased significantly in all five patients by 10 and 15 min after tumor removal. All five patients had histologically proven ACTH-secreting bronchial carcinoid tumors, suppressed plasma ACTH by 24 h after tumor removal, and subsequent secondary adrenal insufficiency indicating successful surgical therapy (five of five true-positive). In one patient, previous surgery was not curative and did not result in a decrease in intraoperative measurement of ACTH (one of one true-negative). It was demonstrated that a rapid ACTH immunochemiluminescence assay with a 15-min incubation time has sufficient sensitivity and precision to detect decreases in ACTH described above. These results demonstrate that complete removal of ACTH-secreting bronchial carcinoid tumors can be detected intraoperatively by a decrease in arterial ACTH by 15 min. The modification of the ACTH immunochemiluminescence assay to 15 min incubation allows the documentation of a successful tumor removal in the operating room. It may also be used to locate the tumor intraoperatively by selective pulmonary vein sampling. This protocol may be applicable to the intraoperative measurement of ACTH during pituitary microadenomectomy for Cushing's disease.

Successful treatment of post-mitral valve annuloplasty Aspergillus flavus endocarditis.

Aspergillus endocarditis is associated with a very high mortality. Of approximately 67 cases reported in the English language literature, there have been only two known survivors. This report describes a patient with Aspergillus flavus endocarditis after mitral valve annuloplasty who recovered with combined surgical and antifungal therapy. This is the first successfully treated case due to A. flavus and the first involving an annuloplasty ring.

Tricuspid valve replacement for Ebstein's anomaly in childhood with a Starr-Edwards caged-ball prosthesis. 21-year follow-up.

A 21-year follow-up after tricuspid valve replacement (TVR) with a Starr-Edwards caged-ball prosthesis in a ten-year old boy is described. TVR is performed for Ebstein's anomaly, with strict indications in childhood. Despite the current preference for bioprostheses, good performance can be expected from the Starr-Edwards caged-ball valve.

Strut failure of the Starr-Edwards cloth-covered metallic ball prosthesis. Report of two asymptomatic cases and review of the overall experience.

Two cases of asymptomatic strut failure of an aortic Starr-Edwards cloth-covered metallic ball prosthesis are reported. Strut failure can be asymptomatic for years. Available information on the overall worldwide experience of six cases is reviewed and suggestions made for early diagnosis and treatment of this rare complication.

Life-threatening chylothorax after left internal mammary artery dissection: therapeutic considerations.

Persistent chylothorax developed in a 53-year-old man after left internal mammary artery (LIMA) takedown and required surgical intervention. After an unsuccessful supraclavicular approach, left-sided standard thoracotomy showed thick adhesions around the LIMA takeoff with a diffuse oozing rather than an identifiable discrete leak. A possible leaking point was stitched, the area was sealed with fibrin adhesive, and complete remission ensued. Operation for chylothorax after LIMA takedown is challenging. A left-sided standard thoracotomy with minimal dissection and use of fibrin adhesive rather than blind stitching are recommended.

Results of intraaortic balloon pumping after cardiac surgery: experience with the Percor balloon catheter.

One hundred thirty-eight patients undergoing an open-heart procedure required an intraaortic balloon pump (IAPB) postoperatively. In Group I (N = 45), the AVCO femoral conduit surgical technique was used; in Group II (N = 93), the Percor balloon was inserted either in the operating room after groin cutdown (open insertion) or percutaneously in the intensive care unit (percutaneous insertion). IABP usage increased in Group II (3% versus 1.6%; p less than 0.001). Immediate mortality was 40% (55/138). Use of the Percor balloon in Group II resulted in lower immediate mortality (32/93 or 34% versus 23/45 or 51%; p less than 0.06). Delayed mortality from multiorgan failure was 11.6% (16/138). Immediate percutaneous insertion at the bedside rather than a return to the operating room for open insertion yielded lower mortality (2/8 or 25% versus 6/7 or 86%; p less than 0.05). Open insertion of the Percor balloon decreases the failure rate of insertion compared with both the AVCO femoral conduit technique (7/85 or 8.2% versus 5/45 or 11%) and percutaneous insertion. It has more complications than the AVCO femoral conduit technique (7/85 or 8.2% versus 2/45 or 4.4%) and less than percutaneous insertion.

Survival and "event-free" analysis of 785 patients with Björk-Shiley spherical-disc valves at 10 to 16 years.

Seven hundred eighty-five patients underwent Björk-Shiley spherical-disc valve replacement from 1970 to 1976. There were 268 mitral valve replacements (MVR), 227 aortic valve replacements (AVR), 65 double-valve replacements, and 225 "combined" procedures. A 97.2% follow-up (mean, 12 years) was achieved. With an operative mortality of 4.1% for MVR, 8.4% for AVR, 15.4% for double-valve replacement, and 12.4% for combined procedures, the 12-year survival was most closely related to age at valve replacement: age less than 50 years, 70%; age 50 through 59 years, 52%; and age 60 years or more, 38%. Twenty-four patients (3.1%) (6 who had MVR, 5 who had AVR, 1 who had double-valve replacement, and 12 who had combined procedures) had a thrombosed valve 1 to 134 months postoperatively; this is equal to 0.36 thrombosed valve per 100 patient-years. One hundred eighteen embolic episodes occurred in 94 (13%) of the operative survivors or 1.8 emboli per 100 patient-years. There were major bleeding complications in 0.5% of patients and minor bleeding complications, in 4.0%. Endocarditis appeared in 30 patients (4.2%) or 0.4 episode per 100 patient-years and paravalvular leaks, in 20 patients (2.8%). The event-free survival by age group and valve site at 5, 10, and 12 years is presented. Events included death, thrombosed valves, strokes, bleeding, emboli, paravalvular leaks, and endocarditis. There were 5.3 events per 100 patient-years excluding operative deaths.

Improved early results after aortic valve replacement: analysis by surgical time frame.

Primary aortic valve replacement was performed in 430 patients. It was an isolated procedure in 339 and was combined with coronary artery bypass grafting in 91. Of these patients, 282 underwent operation from 1970 through 1976 (time frame 1) and 148 from 1980 through 1985 (time frame 2). They were divided into subgroups by age, New York Heart Association functional class, combined coronary artery bypass graft, and valvular lesion. Overall hospital mortality was 7.7% (time frame 1 = 10.6% versus time frame 2 = 2.0%; p less than 0.01). Overall, functional class III or IV was the strongest predictor of hospital mortality (p less than 0.001). Association of coronary artery bypass graft was the next strongest predictor of hospital mortality (p less than 0.01), and it retained its predictive value in time frame 2. Overall, hospital mortality was higher in patients older than 55 years (10.5% versus 3.5%; p less than 0.05). There were no hospital deaths in patients younger than 55 years in time frame 2. Type of valvular lesion was not a predictor of hospital mortality. Hospital mortality in patients receiving cardioplegia was 2%. Cardioplegia use has lessened the effect of age and functional class as predictors of hospital mortality after primary aortic valve replacement. Earlier operation in time frame 2 played a substantial role in the overall improvement of early results.

Open versus endoscopic saphenous vein harvesting: wound complications and vein quality.

BACKGROUND: The saphenous vein is an important conduit for coronary artery bypass grafting. Wound complications from traditional open vein harvesting occur often. Minimally invasive endoscopic saphenous vein harvesting may decrease wound complications. Vein quality may be an issue with endoscopic harvesting. METHODS: We reviewed 568 patients who had bypass grafting and saphenous vein harvesting either endoscopic (group A, n = 180) versus open (group B, n = 388). Both groups were demographically similar and management identical. Wound complication was defined by the need for intervention and included lymphocele, hematoma, cellulitis, edema, eschar, and infection. Multiple vein segments were obtained from 8 patients, 4 from each group, and examined histologically. RESULTS: Wound complications were significantly less in group A (9/180, 5%) versus group B (55/388, 14.2%), p value equal to or less than 0.001. Open harvesting (p< or =0.001), diabetes (p< or =0.001), and obesity (p< or =0.02) were risk factors for wound complication by univariate analysis. By multiple logistic analysis, open harvesting (p< or = 0.0007) and diabetes (p< or =0.0001) were independent risk factors for wound infection. Histologic evaluation of vein samples showed that there was no difference between the groups and vascular structural integrity was maintained. CONCLUSIONS: Endoscopic saphenous vein harvesting was associated with fewer wound complications and infections. Vein quality was not adversely effected because of endoscopic harvesting.

Precipitation of barium chromate in the presence of strontium and lead by complexation followed by volatilization of ammonia.

Cation-release is used to precipitate barium chromate from homogeneous solution in the presence of lead and strontium. MEDTA or DCTA is added to complex the metal ions at pH 10.3 (adjusted with ammonia). On heating, the ammonia slowly volatilizes and the consequent increases in acidity releases the metal ion bound in the least stable chelate (barium). Precipitation is about 99.3-99.7% complete at pH 6.7-6.8, with less than 0.1% co-precipitation of lead or strontium. Lower pH values can be attained by volatilizing acetic or hydrochloric acid into the solution in a closed system.

Vasodilator effects of the sodium acetate in pooled protein fraction.

Paradoxical hypotension during rapid infusion of plasma protein fraction (PPF) has been attributed to vasodilation by bradykinin in PPF. This study employed a canine, controlled right heart bypass preparation to assess changes in systemic vascular resistance and venous capacitance during infusion of PPF and other possibly vasoactive mediators. Plasma protein fraction caused consistent vasodilation, whereas purified human albumin did not. This vasodilation could be ascribed entirely to acetate, present in PPF as a buffer. Bradykinin in PPF had no effect during venous infusion. Acetate is used widely as a buffer in intravenous and dialysate solutions. Its vasoactive properties must be recognized when such solutions are administered to patients with limited capacity to compensate for sudden vasodilation.

Compression of the right pulmonary artery by aortic aneurysms: CT demonstration.

Two cases are presented in which compression of the right pulmonary artery by thoracic aortic aneurysm was demonstrated using dynamic CT. The patients initially presented with symptoms suggestive of pulmonary embolus and were found to have unilateral absence of perfusion on isotope lung scan. Computed tomography was useful in demonstrating pulmonary artery compression by aortic aneurysm as the cause in both cases, and in demonstrating an aortic dissection in one case.

Coarctation of the aorta and baroreceptor resetting. A study of carotid baroreceptor stimulus-response characteristics before and after surgical repair in the dog.

We studied baroreceptor function in dogs before and after surgical repair of coarctation of the aorta by direct recording of multifiber carotid sinus (CS) nerve activity (NA) during alteration of pulsatile arterial pressure with systemic phenylephrine and nitroprusside, and during static pressure changes using a CS pouch preparation. Coarctation was induced by banding the proximal thoracic aorta in ten 3- to 5-day old puppies. One and one-half years later, five of these coarctated animals were studied before, and five were studied 3-7 months after, surgical repair. Five adult animals also were studied 4-6 months after the proximal thoracic aorta had been banded. Controls were eight normal adult dogs. Threshold pressure at which NA began, saturation pressure at which NA reached a maximum, and slope (% Max NA/mm Hg) of the linear portion of the stimulus-response curve were determined. Pulsatile manipulations of pressure elicited normal sensitivity (slope) in dogs with coarctation but static nonpulsatile pressure changes showed depressed sensitivity compared to controls. After surgical repair, threshold and saturation returned toward normal; sensitivity determined with static pressure manipulations returned to control value. Coarctation reset CS baroreceptors to operate at higher pressures in both puppies and adult dogs and repair of coarctation returned function toward normal. We conclude that resolution of hypertension after repair of coarctation may depend upon baroreceptor readaptation.