Chylothorax as a manifestation of rheumatic mitral stenosis: its postoperative management with a diet of medium-chain triglycerides.

Chylothorax occurred as a manifestation of severe congestive heart failure resulting from rheumatic mitral stenosis. Following replacement of the mitral valve, chylothorax recurred and was treated by thoracocentesis initially and then resolved during six months of therapy with a diet of medium-chain triglycerides. Ultimately, the patient resumed a regular diet with no further accumulation of pleural fluid.

Cardiac pheochromocytoma originating in the interatrial septum.

A 36-year-old woman with classic clinical and biochemical features of pheochromocytoma was found to have a cardiac pheochromocytoma originating in the interatrial septum and a significant obstructive lesion in the left anterior descending coronary artery. Complete resection of the pheochromocytoma and an aortosaphenous vein graft were performed. This is the first reported case of successful resection of an interatrial pheochromocytoma.

A cluster of sternal wound infections requiring muscle flap repair: problems in epidemiologic investigation.

A cluster of sternal wound infections (SWI) requiring muscle flap closure occurred in a California hospital in 1988. Review of SWI rates by surgical team revealed that a single team (Team A) was associated with a cluster of SWI requiring muscle flap repair (MFR). Team A's rate of SWI requiring MFR was 2.27% in 441 heart operations. A case/control study was conducted to determine if the higher rate of SWI requiring MFR could be attributed to disproportionately large numbers of patients at high risk treated by Team A. Data on major risk factors for SWI collected for case and control groups included the following: age at operation, weight, body surface area, history of obesity, diabetes mellitus, or cigarette smoking, duration of cardiopulmonary bypass, use of internal mammary artery graft, number of coronary arteries bypassed, use of prostheses, operating room staffing, and emergent nature of operation. No statistically significant differences between Team A cases requiring MFR and control cases were observed for predisposing risk factors. Surgical technique remains a principal suspected risk factor for SWI requiring MFR in this cluster.

Acute clonidine withdrawal syndrome following open-heart operation.

A patient who underwent cardiopulmonary bypass developed a syndrome of malignant hypertension with agitated delirium, unresponsive to antihypertensive agents, following abrupt withdrawal of clonidine. The literature on this syndrome is reviewed with emphasis placed on prompt recognition. The syndrome can be reversed by resumption of clonidine administration and can be prevented by maintenance of clonidine levels through the perioperative period.

Fatal quinidine-induced thrombocytopenia following open-heart surgery.

Three patients developed quinidine-induced thrombocytopenia within 3 months of our initiating quinidine therapy after open-heart surgery. One patient recovered from thrombocytopenic purpura after quinidine was discontinued. The 2 other patients presented with thrombocytopenic purpura and gingival bleeding over several days. Both patients developed headaches and succumbed to intracerebral hemorrhage in spite of the immediate cessation of quinidine therapy on admission and treatment with corticosteroids and platelet transfusions. In the light of this experience, we recommend that quinidine therapy of perioperative arrhythmias in patients undergoing open-heart surgery be re-evaluated, both at the time of discharge from the hospital and 1 month postoperatively, with an aim towards earlier discontinuation of quinidine whenever possible. Although a rare occurrence, quinidine-induced thrombocytopenia can evolve into a lethal cerebral hemorrhage. The response to current treatment of this rare complication is unpredictable.