Subcutaneous phaeohyphomycosis caused by Amesia atrobrunnea in Kuwait.

The recently described genus Amesia encompasses four species but only Amesia atrobrunnea (=Chaetomium atrobrunneum) is known to be pathogenic to humans. Here, we describe a case of subcutaneous phaeohyphomycosis in Kuwait in an apparently immunocompetent patient diagnosed by direct microscopy of the infected tissue and culture. The identity of A. atrobrunnea was established by typical morphological characteristics and by sequencing of internally transcribed spacer (ITS) region and D1/D2 domains of rDNA. To the best of our knowledge, this is the first report documenting etiologic role of this species in causing a locally invasive subcutaneous infection.

Experience and results with 150 pulmonary thromboendarterectomy operations over a 29-month period.

A program to alleviate chronic, major vessel thromboembolic pulmonary hypertension by pulmonary thromboendarterectomy was initiated at this institution in 1970. Multiple evolutionary changes in the diagnostic evaluation, surgical approach, and postoperative management have been implemented over the series of 323 thromboendarterectomies performed through March 1992. A sequence of five surgeons at the University of California at San Diego have performed these procedures, with the last 150 having been performed by one surgeon. We report here the changes in surgical approach developed over the last 150 cases and the results obtained. The operation involves a median sternotomy incision, the institution of cardiopulmonary bypass, and deep hypothermia with circulatory arrest periods. Incisions are made in both pulmonary arteries into the lower lobe branches. Pulmonary thromboendarterectomy is always bilateral, with removal of both organized thrombus and an endarterectomy plane from all involved vessels. The right atrium is routinely explored for atrial septal defects. Current techniques appear to allow more thorough revascularization and shorter circulatory arrest times. The surgical mortality of 8.7% over this span is below that previously reported from this and other institutions. Among survivors, the hemodynamic and functional results have been excellent. Surgically correctable chronic thromboembolic pulmonary hypertension likely remains underdiagnosed. The diagnostic, surgical, and postoperative management evolution provided by the coordinated team involved at this institution has established that pulmonary thromboendarterectomy can be performed with an acceptable risk and good hemodynamic and symptomatic results.

Techniques for bronchial anastomosis.

BACKGROUND: Many techniques have been described to optimize the construction of the bronchial anastomosis in lung transplantation. Over the past 60 months we have performed 86 bronchial anastomoses in 70 patients receiving single lung or bilateral single lung transplants. METHODS: No anastomosis was wrapped and no attempt was made at revascularization of bronchial arteries. A continuous nonabsorbable suturing technique was used in all cases. Standard triple-drug immunotherapy with cyclosporine, azathioprine, and prednisone (starting at day 7) was used for each patient. RESULTS: There were no anastomotic leaks, and seven stenoses were identified in five patients (7%). All complications were managed conservatively with stenting, and there were no related deaths. Mean time to stent placement was 109 days. One patient had bilateral stents placed prophylactically during an episode of severe infection for questionable anastomotic viability but without evidence of airway necrosis or obstruction. This patient died of infection at 16 days. Another patient died with stents in place at 71 days. In the four remaining patients, all stents have been removed after a mean of 310 days. These patients were followed up with serial bronchoscopy and were without evidence of recurrent obstruction at 2, 34, 35, and 36 months. Six of seven stenoses occurred in patients with cystic fibrosis. In each patient where stenosis developed the anastomosis was telescoped. Since abandoning the telescoping technique in the remaining 50 anastomoses (14 in patients with cystic fibrosis), no dehiscence or stenosis was encountered. CONCLUSIONS: These data suggest that elaborate techniques aimed at construction of the bronchial anastomosis are not necessary. Moreover, attempts at telescoping may be detrimental. Patients with cystic fibrosis may be a population at higher risk for anastomotic complications. Airway complications can be managed conservatively with good results and little risk to the patient.

Results of surgical treatment of periampullary tumors: a thirty-five-year experience.

Data on 126 consecutive patients with periampullary tumors resected at the Cleveland Clinic between January 1950 and December 1984 were reviewed. One hundred five patients underwent pancreatoduodenal resection, 10 patients total pancreatectomy, and 11 patients local resection of the tumor. The site of tumor was ampulla of Vater (59), head of the pancreas (30), duodenum (20), and distal common bile duct (11). Six patients had benign disease. The operative mortality rate for radical resection for the entire period was 7.8%; it has declined to 5.4% since 1974. The operative mortality rate for local resection was 9.1% (one patient). The overall 5-year survival rate for all malignant tumors of the periampullary area was 28% and 25.5% for invasive adenocarcinoma. Survival was affected primarily by location and histologic findings. The 5-year survival rate for adenocarcinoma of the ampulla of Vater was 37.2%, 27.5% for the duodenum, 16.7% for the distal common bile, and 4.3% for the pancreas (p = 0.0001). Papillary adenocarcinoma had a 5-year survival rate of 49.2% in contrast to 18.4% for nonpapillary ductal adenocarcinoma (p = 0.002). Patients with ampullary adenocarcinoma treated by local resection had a 5-year survival rate of 40.9%. These data justify continued use of a selective radical approach in the resection of most periampullary tumors with local resection for small tumors in high-risk patients.

Surgical management of spontaneous left main coronary artery dissection.

Two cases of spontaneous left main coronary artery dissection are reported. This condition is rare and may present as an urgent surgical dilemma. The presentation, diagnosis, and management of primary left main coronary artery dissection are reviewed. Causative factors and underlying pathology are clarified. Prompt diagnosis and surgical intervention with temporary ventricular support is safe and effective.

Characterization and surgical resection of an organized pericardial hematoma assisted by transesophageal echocardiography.

We describe the echocardiographic features of a rare pericardial hematoma causing elevated venous pressure in a patient who had suffered blunt chest trauma in the past. Transesophageal echocardiography demonstrated a large, partially calcified mass in the right cardiophrenic angle impinging on the tricuspid annulus and facilitated intraoperative assessment of surgical resection.

Spontaneous coronary artery dissection in patients with renal transplantation.

We describe two patients with spontaneous coronary artery dissection (SCAD) while on immunosuppressive therapy following renal transplantation. The role of cyclosporine A as a potential etiologic factor in spontaneous coronary artery dissection is discussed. A review of the recent literature on spontaneous coronary artery dissection highlights the changing clinical presentation and management of these patients.

Risks associated with removal of ventricular epicardial pacing wires after cardiac surgery.

BACKGROUND: Epicardial pacing wires are routinely used for the diagnosis and treatment of bradyarrhythmias after cardiac surgery. The frequency of arrhythmias during removal of the wires is unknown, and methods of removal vary among institutions. OBJECTIVES: To describe the frequency of ventricular arrhythmias during removal of epicardial pacing wires from the right ventricle, to determine variables that are predictive of ventricular arrhythmias during wire removal, and to describe patients' perceptions of wire removal. METHODS: A convenience sample of 145 patients who had undergone cardiac surgery was studied during the course of 1 year. Electrocardiographic and vital signs were recorded throughout wire removal. Patients' records were reviewed for variables that could predict the occurrence of arrhythmias during wire removal: laboratory values, history of arrhythmias, medications, medical history, postoperative course, and pain reported by the patient. RESULTS: Sixty-six percent of patients had one premature ventricular contraction or more while the ventricular wires were being removed. Seven percent of patients had nonsustained ventricular tachycardia during wire removal. Patients who had repeat cardiac surgery had significantly more nonsustained ventricular tachycardia than did all other patients (P < .01). Only a history of heart failure (P < .02) was a significant predictor of premature ventricular contractions during wire removal. On a scale of 0 (no pain) to 10 (worst pain), the mean rating of pain intensity reported by patients was 2.39 (SD = 2.77). CONCLUSION: Patients may be at risk for ventricular arrhythmias during removal of epicardial pacing wires. Findings support the need for electrocardiographic monitoring while pacing wires are being removed.

The Registry of the International Society for Heart Transplantation.

As of October 1990, the Registry of the International Society for Heart Transplantation has received data on over 14,000 heart and over 1,100 combined heart-lung or lung transplant recipients from over 200 centers worldwide. While the areas of single-lung transplantation and pediatric heart transplantation continue to expand rapidly, further growth in annual numbers of cardiac and pulmonary transplant procedures is now limited by donor supply. Operative mortality and late survival have improved during the past decade, however, infection and rejection continue to be the main causes of death. As the number of long-term survivors continues to increase, chronic rejection remains the major obstacle and results with retransplantation have not been very encouraging.

The Registry of the International Society for Heart Transplantation.

The International Society of Heart Transplantation Registry has now received data on almost 12,000 transplants including over 11,000 heart transplants and almost 600 heart-lung and 100 lung transplants. Recently, a plateau in number of transplants per year has become evident. It appears that further growth is now limited by donor supply. Operative mortality and long-term survival rates continue to show gradual improvement. Organ preservation and other intraoperative complications remain a major factor associated with operative mortality, especially in heart-lung and lung transplantation. Infection and rejection remain the most common causes of early and late deaths. An increasing number of patients have now received second transplants. At the present time, results with retransplantation are significantly worse than for the initial transplant.

Effects of a videotape information intervention at discharge on diet and exercise compliance after coronary bypass surgery.

BACKGROUND: This study evaluated the relative effects on compliance with recommended lifestyle changes of two experimental videotapes that involved different approaches for preparing coronary artery bypass graft (CABG) patients for the posthospital recovery period. The tapes differed in the extent to which they portrayed the recovery period as a steady, forward progression versus a series of "ups and downs." METHODS: Two hundred sixteen male and female CABG patients were assigned randomly either to view one of the two videotapes before discharge from the hospital or to receive only the standard discharge preparation provided by the hospital. All patients completed measures of anxiety and self-efficacy at discharge, 1 month and 3 months after discharge from the hospital. Patients also completed measures of dietary fat consumption and activity level 1 and 3 months after discharge. RESULTS: Relative to controls, patients who viewed either of the videotapes before hospital release reported higher self-efficacy for adhering to the recommended low-fat diet both at discharge and 1 month after surgery. Viewing either of the videotapes also resulted in significantly less dietary fat intake 1 month after hospital release compared with controls. Patients who viewed the tape that portrayed the recovery period as consisting of ups and downs also reported significantly more frequent moderate exercise at 1 month and more frequent strenuous exercise 3 months after discharge. CONCLUSIONS: The experimental videotapes proved to be an effective method for increasing dietary and exercise compliance during the first 3 months after CABG.

Symptomatic coronary-subclavian steal corrected by carotid-subclavian bypass.

Angina recurred after a left internal mammary-to-left anterior descending coronary artery bypass graft. Subsequent development of a subtotal stenosis in the proximal left subclavian artery caused reversal of flow in the patent internal mammary artery graft, which produced an angiographic steal of myocardial perfusion. Angina and ischemia were relieved by reoperation, which consisted of left common carotid-to-left subclavian artery bypass in conjunction with right internal mammary-to-right coronary artery bypass and aorto-to-lateral circumflex coronary artery bypass with reversed saphenous vein.

Simultaneous aortic reconstruction and renal revascularization: risk factors and late results in eighty-nine patients.

From 1973 through 1984, graft replacement of infrarenal aortic aneurysms (N = 56) or occlusive disease (N = 33) was performed in conjunction with simultaneous renal revascularization in 89 patients. Isolated renal artery stenosis was corrected by unilateral reconstruction in 56 patients (63%), but the remaining 33 (37%) had diffuse involvement that required either bilateral renal artery grafts or unilateral revascularization of solitary kidneys. The incidence of hypertension (greater than 180/90 mm Hg) refractory to preoperative medical therapy (88%), severe coronary disease documented by angiography (40%), and postoperative azotemia (33%) or oliguric renal failure (15%) was significantly higher among patients with bilateral renal artery disease (p less than 0.05). In addition, this group had twice the early mortality rate (15%) of patients having unilateral renal artery lesions (7.1%). During a mean follow-up interval of 37 months, medical control of hypertension was enhanced in 46 of the 80 operative survivors (58%), and renal function improved or remained stable in 63 survivors (79%). Five-year actuarial survival presently is 65% for the entire series, with a cumulative mortality rate of 38% among patients who underwent aneurysm resection (mean age 64 years) in comparison to 15% (p = 0.03) for those patients with aortoiliac occlusive disease (mean age 60 years).

Relation between upper limit of vulnerability and defibrillation threshold in humans.

BACKGROUND: In the canine model, an upper limit of shock strength exists that can induce ventricular fibrillation during the vulnerable period of the cardiac cycle. This shock strength (the upper limit of vulnerability) closely correlates with the defibrillation threshold and supports the "upper limit of vulnerability" hypothesis of defibrillation. It is not known whether an upper limit of vulnerability exists in humans or whether this limit correlates with the defibrillation threshold. METHODS AND RESULTS: In 13 patients undergoing implantable cardioverter-defibrillator implantation, the shock strengths associated with a 50% probability of reaching the upper limit of vulnerability (ULV50) and a 50% probability of reaching the defibrillation threshold (DFT50) were determined by the up-down algorithm. The ULV50 was determined only for the mid-upslope of the positive T waves and for the mid-downslope of the negative T waves. No major complications occurred during surgery. An upper limit of vulnerability was demonstrated in each patient. The ULV50 was 300 +/- 138 V or 6.8 +/- 5.8 J, which was significantly lower than the DFT50 of 347 +/- 167 V (p = 0.038) or 9.1 +/- 7.3 J (p = 0.013). The correlation between the ULV50 and the DFT50 was significant (r = 0.90, p < 0.001 for voltage; r = 0.93, p < 0.001 for energy). CONCLUSIONS: An upper limit of vulnerability is present in humans. There is a significant correlation between the ULV50 and the DFT50, and the ULV50 is significantly lower than the DFT50.