Fatal massive hemoptysis secondary to intralobar sequestration.

We report the case of a 29-year-old woman who died of massive hemoptysis due to hemorrhage from an intralobar pulmonary sequestration into the tracheobronchial tree. The sequestration had been diagnosed in childhood but had been managed nonoperatively. This case emphasizes the need for early surgical treatment of pulmonary sequestration.

Donor cardiectomy for other transplantation centers.

Inadequate supply of donor hearts is the greatest limitation to wider utilization of heart transplantation. We performed donor cardiectomy for other transplantation centers in three cases. The donor heart functioned well in all cases, and the recipients were all discharged. Donor cardiectomy for other transplantation centers allows utilization of hearts that might otherwise be lost for transplantation.

Gonococcal endocarditis complicating pregnancy: a case report and literature review.

The incidence of gonorrhea has decreased substantially in the past decade. Disseminated gonorrhea is more common in women than in men, although gonococcal endocarditis is more common in men. Disseminated gonorrhea is most commonly described in women during menses or pregnancy. Only two cases of gonococcal endocarditis during pregnancy have been reported in the literature since 1942. We report a patient who experienced sudden hemodynamic decompensation at 30 weeks' gestation, resulting in fetal death. Aortic valve replacement was performed, but extensive involvement of the aortic root made complete eradication of infection impossible and eventually resulted in maternal death.

Acute appendicitis during pregnancy. Diagnosis and management.

Twelve patients underwent appendectomy during pregnancy or in the puerperium. The clinical presentation of acute appendicitis is altered during gestation, and diagnosis becomes increasingly difficult when close to term. Abdominal pain, nausea, and vomiting are important symptoms. Peritoneal signs occur in the right lower quadrant early in pregnancy, but the upper quadrant or entire right side are more common locations, as the appendix is displaced upward by the enlarging uterus. Delay in treatment is common because of uncertainty in making the diagnosis and hesitancy to proceed with surgery. In the group of six patients with perforation, there was one maternal death and a loss of three fetuses. There were no complications in the absence of perforation. Prompt diagnosis is the cornerstone of a good outcome, and early surgical intervention is indicated if acute appendicitis is suspected. Pregnancy is not a reason to delay surgery. We review the literature on this topic and present and analyze principles of management.

Massive hematuria following percutaneous biopsy of renal allograft. Successful control by selective embolization.

We report on a patient who underwent a percutaneous needle biopsy of a renal allograft for evaluation of compromised function. Gross hematuria occurred immediately and persisted for three weeks, interrupted only by long intervals of anuria due to obstruction by a clot. The bleeding was controlled successfully by selective transcatheter embolization with a coli and an absorbable gelatin sponge (Gelfoam). The techniques and complications of allograft biopsy procedures are reviewed, and the management of hematuria occurring after a percutaneous needle biopsy is discussed. A percutaneous needle biopsy is the preferred method of sampling the transplanted kidney, with an adequate specimen obtained in 96% of cases. Hematuria, that has been reported to complicate 7% of percutaneous biopsy procedures, is usually transient, and only rarely is intervention required. Angiographically directed selective embolization is an effective technique for controlling massive or prolonged urinary hemorrhage after renal allograft biopsy.

A venous reservoir for cardiopulmonary bypass in newborns and small infants.

A venous reservoir has been designed for cardiopulmonary bypass in newborns and small infants that prevents undesirable volume shifts and thus permits precise control of perfusion.

Thoracotomy through the auscultatory triangle.

We present a technique of thoracotomy through the auscultatory triangle. Good access to the thoracic cavity is obtained, and both latissimus dorsi and serratus anterior muscles are preserved. There is reduced postoperative morbidity.

Late complications of plombage.

Plombage was used commonly in the management of tuberculosis before the early 1950s. From 1977 through 1990, 4 patients were seen with complications of plombage performed decades previously. Lucite spheres were used in 3 patients and paraffin in 1. One patient had bilateral apical plombage. In all cases, complications were related to infection or migration of the foreign material. Two patients had extrusion of foreign material or fluid into the chest wall. One patient had hemoptysis and infection due to erosion of a Lucite sphere into the lung. Another had intestinal obstruction subsequent to erosion into the esophagus. The patient with bilateral plombage had development of asynchronous complications on both sides. Treatment consisted of removal of the foreign material and individualized management of the remaining space. There were no operative deaths and the outcome was good in all cases.

Intraaortic balloon entrapment.

A review of intraaortic balloon pump use at the University of Miami/Jackson Memorial Medical Center over the past 21 years identified 2 cases where a balloon was found to be entrapped. The balloon catheters had been in place for approximately 10 days when this complication occurred. The retained balloons were torn, filled with clotted blood, and impacted in the vasculature. In our first case, forceful removal of the intraaortic balloon was complicated by unintentional extraction of the external iliac and common femoral arteries. In the second case, clot within the balloon was dissolved with tissue plasminogen activator injected into the drive lumen of the catheter before removal. The prevention and management of this rare but serious complication of intraaortic balloon pumping is reviewed.

Pulmonary artery banding: analysis of a 25-year experience.

A 25-year experience (May 1962 through April 1987) with pulmonary artery banding in 183 patients was reviewed and analyzed. Pulmonary artery banding was performed in a heterogeneous group of patients aged two days to 60 months (median, 10 weeks; mean, 21.8 weeks) and weighing 1.4 to 13.8 kg (mean, 4.2 kg). Diagnosis was ventricular septal defect in 76 (41.5%) and atrioventricular communis in 41 (22.4%). Pulmonary artery banding was also used in patients with d-transposition of the great vessels with ventricular septal defect, double-outlet right ventricle, univentricular heart, tricuspid atresia, and truncus arteriosus. Early death occurred in 39 of 175 patients who underwent pulmonary artery banding at Ochsner Foundation Hospital (22.3%). Definitive operation has been performed in 37 of the patients who underwent pulmonary artery banding since 1979 with excellent outcome in 32 (86.5%). Pulmonary artery banding is a useful palliative procedure for a diverse group of patients with congenital cardiac anomalies and unrestricted pulmonary blood flow. With improved results of primary repair of intracardiac anomalies in small infants, however, pulmonary artery banding should be reserved for severely ill patients with complex lesions not amenable to early definitive correction. Currently, pulmonary artery banding is indicated in patients with excessive pulmonary blood flow and single ventricle or tricuspid atresia. Pulmonary artery banding is also appropriate in certain patients with atrioventricular communis and in patients with muscular or multiple ventricular septal defects. Pulmonary artery banding is an option in patients with ventricular septal defect and coarctation of the aorta.

Hyperbaric oxygen: value in management of nonhealing saphenectomy wounds.

The greater saphenous vein is commonly used as a conduit for arterial bypass in both cardiac and peripheral vascular operations. Although saphenectomy wound complications occur infrequently, such problems may be quite serious. We report a case in which hyperbaric oxygen therapy was extremely valuable in the management of a very difficult saphenectomy wound.

Sequential internal mammary artery grafts for coronary artery bypass.

From 1985 to 1990, 145 patients underwent isolated coronary artery bypass with one (n = 128) or both (n = 17) internal mammary arteries (IMAs) used as sequential bypass grafts. All but 2 patients had angina pectoris preoperatively. A total of 162 sequential IMA grafts were constructed bypassing two (n = 152) or three (n = 10) coronary artery sites as in situ (n = 132) or free (n = 30) grafts. In 12 patients, one IMA was used as a nonsequential graft. Thirty-day mortality was 2.8% (n = 4 patients). Perioperative myocardial infarction occurred in 1 patient (0.7%). Only two sequential IMA grafts failed. Both were used to bypass coronary arteries 1.00 mm in diameter. Mean follow-up was 31 months (range, 6 months to 4.2 years). There were three late deaths. Of 136 survivors followed-up, 121 (89%) were free of angina. Postoperative rotational thallium 201 tomography was done in 73 patients. Myocardial ischemia was detected in 11 diabetic patients (15.1%), but corresponded to a sequential IMA graft in 4 (5.5%) and to nonsequential and venous grafts in 10 patients (13.7%). Coronary revascularization with sequential IMA grafts was safe and effective.

Resection of right atrial lymphoma in a patient with AIDS.

Although cardiac problems are common in acquired immunodeficiency syndrome, there is limited experience with heart surgery in this group of patients. We report a case in which a right atrial lymphoma was resected to alleviate tricuspid valve obstruction in a patient with AIDS. The patient did well for approximately 7 months. At that time, he developed multiple complications of AIDS and deteriorated rapidly; he died 8 months after operation. Cardiac surgery can be successfully performed in AIDS patients. However, the late outcome is compromised by the nature of the underlying viral infection.

Pneumothorax in AIDS patients: operative management.

Acquired immunodeficiency syndrome (AIDS) is a devastating disease. Pneumocystis carinii pneumonia (PCP) is a major clinical manifestation of AIDS. A 2-year experience with eight operations for PCP-associated pneumothorax in seven AIDS patients was reviewed. Initial treatment was tube thoracostomy in all cases. Operation was performed because of inability to expand the lung and/or persistent air-leak. Time from insertion of the initial chest tube to operation was 9-66 days (mean, 33 days). Pulmonary air leaks were closed with surgical staples and/or sutures. Chest tubes were removed 3-16 days after surgery (mean, 8.5 days). There were no cases of postoperative respiratory insufficiency and there were no deaths. Patients were discharged from the hospital 6-18 days after surgery (mean, 13 days). The postoperative hospital stay was substantially shorter than the preoperative period of nonoperative therapy (13 vs. 33 days). Follow-up is complete in six of the seven patients. Three patients died of AIDS 4-8 months after surgery (mean, 6 months). Three patients are alive 7-14 months after operation (mean, 11 months). Operative management of PCP-associated pneumothorax is effective and can be performed with low morbidity and mortality. We conclude that surgery should be considered as an early option in AIDS patients with PCP-associated pneumothorax.

Intra-aortic balloon counterpulsation in penetrating cardiac trauma.

A case is presented in which the intra-aortic balloon pump (IABP) was used to successfully manage cardiogenic shock in a patient with a cardiac stab wound, not involving a coronary artery.