Sustained ventricular tachycardia associated with influenza syndrome in a young girl--a case report

Ventricular arrhythmias in children with no demonstrable heart disease are rare. In a thirteen-year-old girl, a typical influenza syndrome was complicated by sustained ventricular tachycardia. Exercise tests, echocardiography, electrophysiological studies, and endomyocardial biopsy were negative. Viremia, fever, or medications may be responsible for this unusual complication.

Ruptured abdominal aortic aneurysms: experience with 70 cases

During the period 1965-1983, 270 patients underwent resection of abdominal aortic aneurysm. In 70 patients (26%) the aneurysm was ruptured. Overall hospital mortality of patients with ruptures was 34%. Five patients died before the graft could be completed. Common denominators associated with mortality were hypotension, renal failure, cardiac arrest, and postoperative hemorrhage. The average age over the first 10 years was 68, but subsequently, has risen gradually, with a corresponding increase in mortality despite improved surgical technique and postoperative care. Only with more widespread elective resections and earlier diagnosis of rupture followed by prompt operative management, can the outlook for patients with abdominal aortic aneurysm be improved.

Iatrogenic left main coronary artery stenosis following PTCA or valve replacement

We report three patients who developed iatrogenic severe left main coronary artery stenosis. In two, it was secondary to coronary cannulation during aortic valve replacement and in one it followed distention of the artery during balloon dilatation of a proximal lesion in the left anterior descending artery. In all three, the stenosis was clinically manifest a few months after the intervention. All were successfully treated by aortosaphenous coronary bypass. A common mechanism for the three cases may be mechanical distention of the left main coronary artery resulting in intimal damage with secondary fibrosis and stenosis. The percutaneous transluminal coronary angioplasty-related stenosis is, to our knowledge, the first reported case of this nature, and represents a previously unrecognized complication of this procedure.

Risk of combined coronary artery bypass and mitral valve replacement

During a period of 6 years and 5 months, a group of 26 men and 16 women between 53 and 80 years of age underwent combined coronary artery bypass and mitral valve replacement. All patients were catheterized preoperatively, and hemodynamic and surgical variables were noted. In accordance with the variables, operative mortality was evaluated and compared among subgroups. Eight patients died, and the factors found to adversely change successful treatment were instability of ischemia, advanced New York Heart Association functional class, severe mitral regurgitation, associated aortic regurgitation, extensive coronary artery disease, the extent of left ventricular dysfunction as estimated by left ventricular end-diastolic pressure and ejection fraction, and elevated pulmonary vascular resistance. Prolonged operative time was also significant. The only variable that did not seem to influence mortality was the pathology type of mitral valve involvement. Analysis of our data confirms the high risk of coronary artery by pass combined with valve replacement for mitral regurgitation reported by others, and it appears advisable at present to exercise caution in recommending combined coronary artery by pass and mitral valve replacement in patients with extensive coronary artery disease and advanced left ventricular dysfunction. Pre-and postoperative utilization of afterload reduction, with the use of circulatory assist devices, may prove effective in some patients, and deserves special evaluation.

Carotid surgery without angiography

We propose that circumstances exist in which angiography is not necessary or is unwarranted for the diagnosis and treatment of carotid arterial disease. High quality real-time B-mode ultrasonographic imaging, combined with both pulsed gated, and continuous wave Doppler analysis, shows a remarkably close correlation with the pathologic abnormality identified at operation. Scanning in the vascular laboratory not only provides quick, noninvasive, accurate assessment of the atherosclerotic disease, it can also provide plaque and blood flow detail not previously attainable. Carotid surgery can be effectively and safely performed in selected patients with the aid of ultrasonography and Doppler analysis without the need for invasive angiographic imaging.

Surgical experience following percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) was attempted in 600 patients, 97 of which were considered unsuccessful. Review of our surgical experience in a large series of these procedures helps to confirm some facts regarding the unique interaction between these two modalities of myocardial revascularization. Serious complications are still relatively common, even when PTCA is performed in centers with broad experience. While emergency operation is not required in all major complications, about 7% of patients need immediate surgical intervention, which is usually performed on unstable patients, and thus associated with increased morbidity and mortality. The combined incidence of major complications, such as coronary dissection, occlusion, and spasms, still approaches 20% of attempts. In contrast to other studies, surgical mortality and morbidity do not appear to be higher in our series of operations on patients with complicated PTCA than in coronary bypass operations in general. This fact may attest to our practice of alerting all surgical services in anticipation of problems. Our short complication-to-operation completion time, averaging 123 minutes, may be partially responsible for the good results. We conclude that standby open-heart services for PTCA are warranted in most hospitals; however, it should not be performed in hospitals without surgeons who are experienced in the practice of open-heart surgery.

Sequential internal mammary-coronary artery bypass

Since April, 1977, a total of eight patients have undergone sequential bypass grafting of the internal mammary artery (IMA) to the coronary arteries at our institution. The indication for this newly described procedure was either insufficient supply of adequate veins (four patients) or the presence of a diseased aortic wall (two patients). Operative procedures included left IMA bypass to the left anterior descending (LAD) artery and its major diagonal branch in six patients; to the obtuse marginal branch and distal circumflex artery in one patient; and to two consecutive sites on the LAD in one patient. All patients became angina-free after operation for a follow-up period lasting up to 6 years. Recatheterization studies were performed in four patients, in all of whom the IMA sequential grafts were found patent. We believe that IMA sequential grafting is an important option available to the cardiac surgeon in managing some patients with coronary artery disease.

Internal mammary coronary artery bypass surgery: experience with 1000 cases

A study of 813 men and 187 women who underwent internal mammary artery (IMA) bypass from 1976 to the present time is presented. In approximately 10% of patients, only the IMA was used for coronary artery bypass, and in approximately 90%, one to four saphenous vein grafts were used additionally. Hospital mortality in the series was 1.8%. The IMA, when properly selected and carefully harvested, is considered an excellent conduit for myocardial revascularization. Disadvantages include its limited application to the proximal portions of one (or two) coronary vessels, a relatively delicate and difficult anastomosis, and an allegedly high incidence of postoperative chest wall discomfort with pulmonary complications. However, this experience with IMA coronary artery bypass supports the view that it is an ideal conduit for the anterior wall when conditions permit its use.