A cluster of severe postoperative bleeding following open heart surgery

OBJECTIVE

To investigate a cluster of postoperative bleeding following open heart surgery.

DESIGN

A cohort and case/control study.

SETTING

Palo Alto Veterans Administration Medical Center, Palo Alto, California.

PARTICIPANTS

Six (21.4%) of 28 patients undergoing open heart surgery who developed severe, nonsurgical, postoperative bleeding from July 1 through August 30, 1988 (outbreak period). All case-patients had chest tube drainage of greater than or equal to 1000 ml within 4 hours of surgery but did not have identifiable bleeding vessel(s) on exploration.

RESULTS

Upon comparison of the pre-outbreak (January 1986 through June 1988) and the outbreak period, a significant increase was found in the incidence of postoperative nonsurgical bleeding (5/440 versus 6/28, p = .0006), but not of postoperative surgical bleeding (8/440 versus 0/28, p = 1.0). Of all patients undergoing open heart surgery during the outbreak period, case patients were found to be older (67.8 versus 60.6, p = .02) and to have received a larger volume of hetastarch (HES), a synthetic colloidal plasma-volume expander (mean = 19.4 ml/kg versus 14.1 ml/kg, p = .02).

CONCLUSIONS

We conclude that the use of large volumes of HES during surgery in the elderly open heart surgery patient may increase the risk for severe, nonsurgical postoperative bleeding, probably caused by alterations of the coagulation system. As the incidence of open heart surgery increases among the elderly, surgeons and anesthesiologists should be alert to possible adverse reactions from exposures not associated with adverse reactions in younger patients.

Lung and heart-lung transplantation: the state of the art

Lung and heart-lung transplantation is one of the most rapidly evolving transplantation fields. Survival has been improving with better patient selection, better graft preservation, and better immunosuppression. This paper outlines criteria for patient selection, reviews the surgical options involving lung transplantation, and discusses factors influencing morbidity and survival in these patients. The Cleveland Clinic Foundation experience with these procedures is presented. Lung and heart-lung transplantation has emerged from the experimental realm to the therapeutic, and can now be offered as an effective treatment option to many patients with previously fatal heart and lung disorders.

The Maze procedure: a new treatment for atrial fibrillation

Atrial fibrillation is a dysrhythmia with lethal complications afflicting thousands of people each year. Unfortunately, atrial fibrillation is frequently resistant to medical therapy and other nonsurgical treatments, such as cardioversion and catheter ablation. Past surgical procedures to correct the dysrhythmia have also proved ineffective. A surgical procedure has been developed in which multiple incisions are made in the atrium, creating an electrical maze. The maze procedure restores atrioventricular synchrony while simultaneously preventing macroreentry within the atria. It thereby eliminates the clinical sequelae often associated with atrial fibrillation and improves the quality of life for those patients refractory to current methods of treatment.

Clinical experience with the Novacor ventricular assist system. Bridge to transplantation and the transition to permanent application

At Stanford University, a Novacor left ventricular assist system (Baxter Healthcare Corporation, Novacor Division, Oakland, Calif.) was placed as a bridge to heart transplantation in 13 patients. During the hospitalization preceding device implantation, all patients were receiving inotropic support for biventricular failure, 11 had pulmonary edema, 6 had life-threatening ventricular arrhythmias, 5 had liver dysfunction with coagulopathy, and 2 had renal failure necessitating artificial support. The mean cardiac index before implantation of the Novacor system was 1.5. All survivors with the Novacor device had a dramatic increase in cardiac output (mean cardiac index = 3.1). One patient with cardiac allograft rejection died during implantation of the left ventricular assist system. Two patients died of pulmonary sepsis and multiorgan failure after the device was implanted. All patients who had the Novacor device implanted for more than 7 days were able to walk and ride stationary bicycles while awaiting transplantation. Ten patients (77%) underwent successful heart transplantation after a mean of 18 days' support with the Novacor device. One patient died of presumed sepsis 2 days after transplantation. Nine patients (90%) are alive 4 months to 6 years after transplantation. In the overall United States experience, 68 patients (as of May 1990) have had a Novacor left ventricular assist device implanted. Five were still being supported, 39 had received a transplant (62%), and 35 patients (90%) survived the transplant hospitalization (1 died later). No instances of device failure have occurred. Overall, the Novacor assist system provided effective bridging to transplantation, with posttransplant survival similar to results after routine transplantation. Modifications and improvements based on this clinical experience have been made in the areas of patient selection, techniques of operative placement, postoperative management, and design of the assist system. Isolated left heart support with a fully implantable left ventricular assist system will be offered as an alternative to heart transplantation for selected patients by 1992.

Single-lung transplantation with atrial septal defect repair for Eisenmenger's syndrome

Heart-lung transplantation has been used successfully for patients with pulmonary vascular disease but its application has been very limited due to the scarcity of donors. We report a patient with Eisenmenger's syndrome who underwent right single-lung transplantation with closure of atrial septal defect; postoperative convalescence was uneventful. Serial magnetic resonance imaging examinations demonstrate improved right heart function.

Retrospective analysis of patients undergoing one- or two-stage strategies for myocardial revascularization and implantable cardioverter defibrillator implantation

Internal defibrillation leads were placed at time of coronary revascularization in 79 patients. In 34, an implantable cardioverter defibrillator (ICD) was placed simultaneously (group I). A two-stage strategy (selective implantation of the ICD in patients with postoperative spontaneous or inducible ventricular tachycardia [VT]) was followed in 45 patients (group II). Group I patients had failed more antiarrhythmic drug trials (2.9 +/- 1.6 vs 1.5 +/- 1.6; P = 0.02), including amiodarone (62% vs 20%; P less than 0.001). There were four operative deaths in each group. Postoperatively, VT was present in 27 group II patients (60%), 25 of whom received an ICD (two refused device implantation). Patients with postoperative VT had a lower left ventricular ejection fraction than those without VT (33 +/- 9 vs 47 +/- 16; P = 0.01). Actuarial survival at 1, 2, and 3 years was 88 +/- 6, 88 +/- 7, and 88 +/- 10 in group I; and 83 +/- 6, 76 +/- 7, and 76 +/- 11 in group II (NS). No patient without an ICD (based on the postoperative electrophysiological study [EPS]) died suddenly. Five patients (6%) had ICD system infection. Sudden death was largely prevented by either strategy, but relatively high rates of operative mortality and ICD system infection were observed. Prospective studies should identify patients more likely to benefit from one or another strategy.

Infections in implantable cardioverter defibrillator patients

Implantable cardioverter defibrillators (ICDs) have been documented as an effective modality in reducing arrhythmic mortality. A serious complication associated with implantation of the device is infection. Few studies have addressed this issue. Two hundred seven patients with refractory ventricular arrhythmias underwent 207 ICD implantations, and 56 subcutaneous generator changes at our institution. Eight patients developed wound infections, four following ICD implantation (4 out of 207 or 1.9%), and four following a generator change (4 out of 56 or 7.1%). Wound cultures most commonly revealed Staphylococcus aureus and Staphylococcus epidermidis. Infections treated with antibiotics alone, or with only generator removal, frequently recurred (four out of five attempts). There were no recurrences following total patch/lead and generator system removal. In five patients, the same generator unit was successfully reimplanted following ethylene oxide sterilization without infection recurrence. We conclude that treatment of device-associated infection generally requires total generator and patch/lead system removal, and that generator units can be successfully reimplanted yielding substantial cost savings.

Improved survival after heart-lung transplantation

Sixty-two patients underwent 65 heart-lung transplant operations before April 1989. Thirty of these patients (operated on March 1981 to February 1986) were given cyclosporine and prednisone for immunosuppression. These 30 patients (group 1) are compared with the 32 most recent patients (group 2) treated with cyclosporine, prednisone, and azathioprine. Patient characteristics (group 1 versus group 2) were similar including age (mean 32 versus 26 years) and indication for operation (51% versus 38%, primary pulmonary hypertension; 46% versus 45%, Eisenmenger complex; 3% versus 17%, other). The perioperative (in-hospital) mortality rate was 35% in group 1 versus 16% in group 2. Obliterative bronchiolitis developed in 12 (63%) of 19 hospital survivors in group 1 from 2 months to 49 months postoperatively (mean 12 months). This complication has developed in five (20%) of the 25 hospital survivors in group 2 from 3 to 13 months postoperatively (mean 8 months). Overall, 24 of the 30 patients in group 1 died (infection in eight, obliterative bronchiolitis in five, graft coronary artery disease in two, other causes in nine). Eight of the 32 patients in group 2 died (infection in six, other cases in two). Survival rates for group 1 patients were 60% at 1 year, 50% at 2 years, 43% at 3 years, and 25% at 5 years. Survival rates for group 2 patients were 73% at 1 year, 73% at 2 years, and 65% at 3 years (p less than 0.05). When group 2 patients were compared with 134 patients undergoing heart transplantation during the same time period, there was no difference in survival. Routine bronchoscopic surveillance in the more recent group of patients has led to the earlier detection of rejection and infection. In combination with decreased perioperative mortality and augmented immunosuppression, this had led to improved survival in our more recent heart-lung transplant recipients. In addition, the earlier recognition of infection and rejection has led to a decrease in severity of obliterative bronchiolitis.

Deoxyribonucleic acid ploidy pattern of cardiac myxomas. Another predictor of biologically unusual myxomas

A group of patients with cardiac myxoma who have a heritable syndrome involving skin myxomas, endocrine tumors, and lentiginosis--the complex of myxomas, spotty pigmentation, and endocrine overactivity--has been described previously. Patients with the complex had cardiac myxomas at an early age (average, 26 years) with frequent multiple myxomas (53%) and recurrent cardiac myxomas (22%); however, no histologic differences were noted when these tumors were compared with sporadic cardiac myxomas. In the present study, deoxyribonucleic acid flow cytometric analyses of 35 cardiac myxoma specimens were correlated with clinical findings (mean duration of follow-up, 13 years). Among 30 patients with sporadic (nonfamilial) cardiac myxoma, 24 (80%) had a normal (deoxyribonucleic acid diploid) ploidy pattern, and six (20%) had an abnormal (deoxyribonucleic acid tetraploid) pattern. Specimens from each of the five patients with the complex had abnormal deoxyribonucleic acid tetraploid patterns (p = 0.002 compared with the sporadic myxoma group). Further, all four patients who had recurrent cardiac myxoma had an abnormal deoxyribonucleic acid ploidy pattern (p = 0.007 compared with patients with nonrecurrent myxomas). Unlike conventional histologic examination, the ploidy pattern of cardiac myxomas seems to be sensitive for detecting biologically unusual tumors, and a deoxyribonucleic acid tetraploid pattern suggests a high risk of recurrence.

Long-term follow-up of patients with benign thyroid fine-needle aspiration cytologic diagnoses

Reliance on fine-needle aspiration (FNA) of the thyroid as the key determinant whether to observe only or proceed surgically is predicated on achieving a minimal false-negative error rate (the incidence of malignant disease in nodules diagnosed benign by means of FNA). To provide convincing data that malignant disease has not been overlooked requires extended follow-up on a large number of patients with cytologically benign lesions. The intent of our study was to assess the long-term accuracy of thyroid FNA-based diagnoses--particularly with respect to false-negative errors. From our total experience of more than 8000 patients, we reviewed the cases of 680 patients who underwent FNA in 1980, the first year we used it clinically. Follow-up information was obtained on 641 (94%) of the patients with a mean time since FNA of 6.1 years. Benign cytologic findings were reported on 439 (68%) of these patients, and only three (0.7%) had false-negative diagnoses. The false-positive rate was 0% for the 24 (4%) patients with positive aspirates. FNA is a safe, reliable, effective means of accurately discriminating benign from malignant thyroid lesions.

Natriuresis during and early after cardiopulmonary bypass: relationship to atrial natriuretic factor, aldosterone, and antidiuretic hormone

Because neurohumoral responses to cardiopulmonary bypass (CPB) are similar to those seen in shock, CPB might be expected to decrease renal blood flow; yet diuresis is commonly observed during and early after routine cardiac procedures with CPB. To examine this apparent paradox, we studied 15 patients before, during, and after CPB for coronary artery bypass grafting. Plasma levels of atrial natriuretic factor (alpha-ANF), aldosterone, and antidiuretic hormone (ADH) and urinary sodium excretion were measured before anesthesia, after sternotomy but before CPB, at 15 and 30 minutes of CPB, and at 15 and 30 minutes after discontinuation of CPB. alpha-ANF increased only slightly during CPB, and the initial natriuresis during CPB occurred in the presence of a markedly increased ADH level. After CPB ended, urine flow and sodium excretion increased in conjunction with increased alpha-ANF and normal ADH. We conclude that the early natriuresis during CPB occurs in the presence of a high ADH concentration, with no significant increase in plasma alpha-ANF. This may be a paradoxic response to supraphysiologic levels of ADH. The natriuresis after CPB appears to be strongly associated with increased alpha-ANF, present for at least the first 30 minutes after CPB, which could reflect alpha-ANF release resulting from atrial distention during volume loading.

Thrombogenicity of canine free internal mammary artery autografts

Early patency of free internal mammary artery (IMA) grafts for coronary artery bypass (CAB) is lower than that of in situ IMA grafts, and proximal anastomotic problems have been implicated in the pathogenesis of graft occlusion. To determine whether thrombotic phenomena might account for proximal graft narrowing, we examined platelet and fibrinogen deposition in 23 free IMA grafts in a canine model of CAB. Twelve animals had no antiplatelet therapy and were controls. Eleven animals received dipyridamole, 55 mg p.o. daily, 2 days before and each day after operation; aspirin, 325 mg p.o. daily, was given after CAB. Six of the 12 untreated dogs and 5 of the 11 treated dogs were sacrificed at 1 day after surgery; the remainder of each group was sacrificed on the 14th postoperative day. Platelet and fibrinogen depositions were quantitated by indium-111 tropolone and Iodine-125 labeling, respectively. Grafts were sectioned into five parts: proximal anastomosis (PA), proximal graft (PG), midgraft (MG), distal graft (DG), and distal anastomosis (DA). Platelet deposition was highest at the PA of free IMA grafts, and fibrinogen deposition was high at both anastomoses. Antiplatelet therapy significantly reduced platelet deposition at the PA at 14 days, but not at 1 day; fibrinogen deposition was significantly reduced at the DA at 1 day, and at both the PA and DA at 14 days. The ratio of fibrinogen molecules per platelet was unaffected by antiplatelet therapy, but was observed to increase with time at the DG and DA.(ABSTRACT TRUNCATED AT 250 WORDS)

Fibrin glue for the treatment of persistent lymphatic drainage

A 7-year-old girl underwent resection of an abdominal wall lymphangiomatous tumor. Postoperative serous drainage, up to 300 mL per day, developed despite application of external pressure to the wound. Thirty-three days after the initial procedure, fibrin glue was applied to the draining tract. Concentrated fibrinogen was prepared from one unit of blood donated by the patient's mother. Ten milliliters fibrinogen and 10 mL thrombin (1,000 U/mL) were injected simultaneously through the wound drain as it was slowly removed, and pressure was reapplied for 48 hours. No further drainage occurred, and at 2- and 14-week follow-up examinations the wound had healed normally without reaccumulation of fluid. Fibrin glue successfully sealed this persistently draining abdominal wall tract. It is a painless, safe, and effective biologic sealant, and when prepared from homologous plasma it carries a low risk of virus transmission.

A cost-effective technique for experimental coronary artery bypass

We describe a method for experimental coronary artery bypass that uses a temporary silicone rubber shunt from the subclavian artery to the circumflex coronary artery to maintain blood flow to the distal myocardium. A major advantage of the technique is the cost savings accrued by avoiding extracorporeal circulation.

Histologic comparison of experimental coronary artery bypass grafts. Similarity of in situ and free internal mammary artery grafts

This study compares patency and histologic structure of in situ internal mammary artery grafts, free internal mammary artery grafts, stripped, free internal mammary artery grafts, and stripped, free superficial femoral artery grafts (a muscular artery model) in a canine model of coronary artery bypass. Twenty-four adult mongrel dogs underwent bypass of the circumflex coronary artery with one of the above grafts. Three months postoperatively, graft patency was assessed by angiogram, and postmortem specimens were studied by intraluminal injection of a dilute barium solution proximal to the graft. Proximal, mid, and distal segments of each graft were examined microscopically. In situ internal mammary artery grafts and free internal mammary artery grafts were not significantly different in regard to patency, vascular wall cellular structure, or perfusion of the vasa vasorum. The stripped, free internal mammary artery group had a higher incidence of thrombosis, intimal thickening, and medial injury than the pedicled (in situ and free internal mammary artery) grafts. This difference may be due to early vascular wall ischemia as a result of poor early perfusion of the vasa vasorum. The stripped, free superficial femoral artery grafts were all patent, but all had adventitial injury.

Effect of blood conservation efforts in cardiac operations at the Mayo Clinic

In a retrospective study of 388 patients who had undergone cardiac operations at our institution during two time periods-before (1982) and after (1984) introduction of autologous transfusion-we analyzed the effect of blood conservation efforts and autologous transfusion on blood usage, postoperative complications, and duration of hospitalization. Cell salvage techniques resulted in a significant reduction (P less than 0.0001) in use of not only homologous blood (from a mean of 9.6 units per patient in 1982 to 3.2 units in 1984) but also fresh-frozen plasma and platelet concentrates. We found no significant difference in morbidity or mortality for the two study periods. Although the mean duration of hospitalization decreased from 11.7 days in 1982 to 9.6 days in 1984, this change was probably related to factors other than the introduction of blood conservation efforts. Thus, techniques used to decrease the amount of blood replacement needed for cardiac surgical procedures are beneficial.

The effectiveness of fibrin glue sealant for reducing experimental pulmonary ari leak

The effectiveness of fibrin glue as a biological sealant for pulmonary air leaks was determined in 16 dogs. A standardized pleural defect was made in the left lower lobe, and the quantity of air passing through a chest tube was assessed with a Collins respirometer. For the 8 randomly assigned control animals, the air leak decreased over 90 minutes from a mean of 1.4 L/min to a mean of 1.1 L/min (mean decrease, 19.8%). In the 8 randomly assigned fibrin glue-treated animals, the air leak decreased from a mean of 2.1 L/min to a mean of 0.5 L/min (mean decrease, 80.8%) (p less than 0.0001). Postoperative evaluation of survivors disclosed no increased adhesions in the glue-treated animals and complete resorption of the glue at 3 months. We conclude that in this animal model, fibrin glue reduced the size of pulmonary air leaks in the early period after thoracotomy and did not lead to increased intrapleural adhesions.

Barium-impregnated fibrin glue: application to a bleeding duodenal sinus

A 64-year-old man with Crohn's disease who had undergone repair of an ileovesical fistula and ileoileostomy had numerous postoperative complications related to sepsis and wound healing. Subsequently, upper gastrointestinal bleeding developed, and the site was identified as a duodenal sinus. Medical management was unsuccessful in controlling the bleeding. Because of the considerable risk associated with reoperation in this seriously ill patient, approval was obtained from the Food and Drug Administration to use fibrin glue in an attempt to prevent further bleeding. The glue was mixed with barium and placed in the duodenal sinus under endoscopic guidance. The barium-impregnated glue facilitated follow-up surveillance with abdominal roentgenography. The patient had no further gastrointestinal bleeding. Further clinical and experimental studies should be conducted to determine the mechanism of action and the efficacy of this application of fibrin glue.

Esophagogastric anastomoses: the value of fibrin glue in preventing leakage

Disruption of an esophagogastric anastomosis can result in a high mortality despite aggressive treatment. The efficacy of fibrin "glue" to seal esophagogastric anastomoses was evaluated as a means of preventing this complication. A left thoracotomy was performed in 25 adult mongrel dogs. After esophagogastric resection, a standardized esophagogastrostomy was performed and eight interrupted sutures were used to completely close the posterior wall. The anterior wall was approximated with only three sutures, leaving four large holes between sutures. The dogs were then randomized into the control group (n = 14; no attempt to seal the leaks) or into the fibrin glue-treated group (n = 11). An average of 3.3 ml of glue was applied to the anterior wall of the anastomosis in the treated group. In the control group, 13 of 14 dogs (92.9%) died of anastomotic leak a median of 3 days after operation. In the fibrin glue-treated group, only four of 11 dogs (36.4%) died of anastomotic leaks (p less than 0.01). Dogs that survived were put to death at 14 days. Postmortem examination in all dogs revealed no deleterious effects or complications related to the glue. Postmortem examination of the one surviving control dog and the seven fibrin glue-treated dogs that did not die of sepsis revealed a healed anastomosis without abscess formation. We conclude that fibrin glue is effective in lessening the incidence of esophagogastric anastomotic leaks as employed in this experimental model.

An aborted, prospective, randomized trial of sclerotherapy for prolonged drainage after mastectomy

Annually, approximately 100 of the 400 postmastectomy patients we studied have persisting serous drainage. Sclerotherapy with the use of tetracycline has been advocated to decrease serous drainage and the formation of seromas. Reports in the literature suggest that the use of tetracycline for treatment has been efficacious and that it is not painful. We devised a prospective, randomized controlled trial to study the effects of tetracycline on patients with prolonged persisting drainage. Six patients in the control group had the drains left in place until the drainage diminished. One of these patients had a seroma develop after the drains were removed. Eight patients were treated with tetracycline. Four of these patients had seromas develop after the drains were removed. Three of the eight patients had severe reactions of pain when the tetracycline was introduced into the drains. Because of the severe pain associated with sclerotherapy treatment and the lack of demonstrable benefit in those treated, we terminated the study. We did not find tetracycline to be of help in treating patients with prolonged drainage after mastectomy and some of those patients had severe pain develop from the treatment.

Social evaluation and the empathy-altruism hypothesis

Archer, Diaz-Loving, Gollwitzer, Davis, and Foushee (1981) suggested that feeling empathy for a person in need may lead to increased helping because the empathic individual wants to avoid negative social evaluation. As support for this suggestion, they claimed that empathy leads to increased helping only under socially evaluative circumstances. We conducted two studies to test this claim. In Study 1 subjects were led to believe that no one--including the person in need--would ever know if they declined to help. In this situation, which was designed to be totally devoid of the potential for negative social evaluation for not helping, there was still a positive relationship between self-reported empathic emotion and offering help. In Study 2 empathy (low versus high) and social evaluation (low versus high) were manipulated in a 2 X 2 design. Once again there was a positive relationship between empathy and offering help when the potential for social evaluation was low as well as high. Results of both studies, then, suggest that the motivation to help evoked by empathy is not egoistic motivation to avoid negative social evaluation. Instead, the observed pattern was what would be expected if empathy evokes altruistic motivation to reduce the victim's need.

The significance of multiple, recurrent, and "complex" cardiac myxomas

We reviewed the Mayo Clinic records of 56 patients who underwent operation for cardiac myxoma and 29 cases in which cardiac myxoma was found at autopsy. Five patients had a "complex" of unusual findings including multiple pigmented skin lesions (lentiginosis), myxoid fibroadenomas of the breast, skin myxomas, and primary pigmented nodular adrenocortical disease (a cause of Cushing's syndrome). Four of these five patients had multiple cardiac myxomas. Three of the four patients who underwent surgical excision of the cardiac myxomas had recurrent myxomas (the only recurrences in our series), and one of these patients had a second recurrence. The occurrence of multiple and recurrent myxomas in patients with the complex was significantly (p less than 0.001) higher than in our 80 patients with sporadic myxomas. The world literature was searched for cases of cardiac myxomas with the unusual associations of the complex, and also for familial, multiple, and recurrent myxomas. A group of patients were identified who had unusual biologic behavior including early development of myxomas, atypical myxoma locations, and a high risk for the development of recurrent myxomas. For these patients, we recommend a thorough search for multiple tumors at operation, close postoperative follow-up, and careful screening of family members.

Social evaluation and the empathy–altruism hypothesis

Archer, Diaz-Loving, Gollwitzer, Davis, and Foushee (1981) suggested that feeling empathy for a person in need may lead to increased helping because the empathic individual wants to avoid negative social evaluation. As support for this suggestion, they claimed that empathy leads to increased helping only under socially evaluative circumstances. We conducted two studies to test this claim. In Study 1 subjects were led to believe that no one--including the person in need--would ever know if they declined to help. In this situation, which was designed to be totally devoid of the potential for negative social evaluation for not helping, there was still a positive relationship between self-reported empathic emotion and offering help. In Study 2 empathy (low versus high) and social evaluation (low versus high) were manipulated in a 2 X 2 design. Once again there was a positive relationship between empathy and offering help when the potential for social evaluation was low as well as high. Results of both studies, then, suggest that the motivation to help evoked by empathy is not egoistic motivation to avoid negative social evaluation. Instead, the observed pattern was what would be expected if empathy evokes altruistic motivation to reduce the victim's need.

The Budd-Chiari syndrome. Medical and surgical management of 30 patients

A retrospective review of 30 patients with documented Budd-Chiari syndrome disclosed an overall mortality of 57%. Medical treatment alone was associated with an 86% mortality; hepatic failure was the most common cause of death. Mortality was 31% overall for the surgical group, but there were long-term survivors among patients undergoing portacaval shunting. From this series, no single surgical procedure was found to be clearly superior. Surgical treatment with a side-to-side portacaval shunt seems to be the preferred operation when it can be performed. Surgical intervention should proceed soon after the diagnosis is made, lest extension of thrombus occur. Medical therapy most often is ineffective.