Late partial tamponade of the right atrium. A case report

An unusual case of late partial tamponade of the right atrium is reported in a patient 35 days after aortic valve replacement. Chest x-rays, echocardiograms and ECG were not helpful. The diagnosis was made by emergency bedside right heart catheterization which showed a 7 cm H2O gradient between the junction of the superior vena cava and right atrium and also a 12 cm H2O pressure difference between the femoral vein and the right atrium with a normal capillary wedge pressure. Re-thoracotomy with evacuation of blood clots and control of bleeding points improved the hemodynamics dramatically. However the patient succumbed 3 weeks later due to irreversible brain damage. This is thought to be the first report of a late partial right atrial tamponade in the English medical literature.

Pneumonectomy in pulmonary mucormycosis complicating Behçet's disease

A 37 year old man with Behçet's disease who was maintained on prolonged corticosteroid therapy, developed diabetic ketoacidosis and pneumonia. Secondary infection with mucor intervened with abscess formation cured by pneumonectomy. The association of Behçet's disease and mucormycosis has not been previously reported, although diabetes mellitus was almost certainly the predisposing cause. Surgical treatment offers the best chance of survival in similar cases.

Closed pericardial drainage for relief of pericardial tamponade

The method of continuous catheter drainage for pericardial tamponade as used in 108 patients is described. The efficacy of this procedure in relieving tamponade resulting from a variety of diseases is demonstrated. Blood clot in the pericardium probably constitutes a contraindication to catheter drainage.

Repair of coarctation of the aorta in the first three months of life

Coarctation of the aorta was surgically treated in 28 infants (16 male, 12 female) aged 2 days-3 months, with 19 younger than 1 month. Body weight at operation was 1.6-4.2 (mean 2.8) kg. 3 infants had coarctation alone, 10 had a wide patent ductus arteriosus as the only associated anomaly and 15 had a variety of other anomalies. Resection with end-to-end anastomosis was performed in only one case, while 21 underwent subclavian flap aortoplasty and six patch graft aortoplasty. Additional procedures were banding of the pulmonary artery in five cases and open aortic commissurotomy in one case. The early mortality was 10.7% (3 infants) and three more died later. Further cardiac surgery was subsequently performed on four of the infants. Of the 22 survivors, two had significant recurrence of coarctation which, however, was successfully corrected in one case. The blood pressure was within normal limits in all survivors, except those with recoarctation.

A new technique for vascular anastomoses

Vascular anastomoses are invariably performed manually and may be difficult technically particularly in smaller calibre vessels. This may be even more pronounced when an emergency situation exists and a surgeon relatively inexperienced in vascular surgery has to deal with the problem. A technique is described allowing for rapid anastomosis of vessels ranging upwards from a diameter of 2.5 mm using incomplete adjustable metal rings. The technique is simple and can be applied by surgeons with minimal vascular training. This could be extremely useful in the emergency situation, particularly when critical ischemia exists. Also, anastomoses of small calibre vessels such as in arterio-venous fistula may be more simply performed by the aid of the described rings.

Proton NMR study of yellowfin tuna myoglobin in whole muscle and solution. Evidence for functional metastable protein forms involving heme orientational disorder

Proton NMR spectra of met-aquo-myoglobin have been recorded in whole dark muscle from yellowfin tuna for the first time; in addition, spectra of the met-aquo, met-cyano, and deoxy forms were recorded in solution. The number of resolved methyl resonances in the met-aquo and met-cyano derivatives of the purified protein indicates a molecular heterogeneity, with the two species present in a ratio of approximately 3:2. These same two species, in very similar environments, are found in whole muscle. Upon reconstitution of the protein, the ratio of the two species is approximately 1:1. Specific isotope labeling in the met-cyano form reveals an interchange of 5-methyl and 8-methyl environments that is characteristic of heme orientational disorder about the alpha, gamma-meso axis. Incubation of the met-cyano protein at 37 degrees C shows that the two species are interconvertible, with the minor component declining to about one-eighth of that of the major component. This indicates that one of the two orientations is favored thermodynamically. The rate of equilibration for the met-aquo protein is exceedingly slow (half-life greater than 30 days), some 10(2) slower than for the analogous sperm whale derivative. The "reversed" heme orientation is therefore present in muscle as a kinetically trapped or metastable species, suggesting that the last step in the biosynthesis of myoglobin is similar to that of in vitro reconstitution. The presence of both heme orientations in myoglobin in whole muscle proves that heme orientational disorder is a physiological phenomenon.

Separation and quantitation of ventricular myosin heavy-chain from human atrial myocardium

A discrepancy observed in electrophoretic mobility of human atrial and ventricular myosin heavy chains permitted the determination of these protein isoforms in myocardial biopsies. In ventricular biopsies we found only the heavy chain specific to this tissue whereas in atrial specimens we sometimes detected an extra heavy chain comigrating with the ventricular species. The peptide mapping of such preparations revealed peptides unique to ventricular heavy chain. Patients suffering from pressure overload expressed ventricular heavy chain at a higher frequency than those suffering from coronary heart disease (66% VS.29%), but this disparity was not found statistically significant (0.1 greater than P greater than 0.05).

Bronchial adenoma: surgical experience with long-term follow-up (4-17 years)

Of 16 patients with bronchial adenoma who were operated on at Beilinson Medical Center from 1967 to 1980, only three presented the "triad" of cough, hemoptysis, and recurrent pulmonary infections. In two patients the tumor was diagnosed incidentally and in five patients histological evidence of adenoma was made during bronchoscopy. One patient died of myocardial infarction following reoperation for bleeding, and one patient was lost to follow-up. The remaining 14 patients were followed for 4 to 17 years without evidence of local recurrence or distant metastases. We conclude that the long-term prognosis of patients with bronchial adenoma is excellent, and limited surgical procedure should be the treatment of choice whenever possible.

Pregnancy after valve replacement with porcine xenograft prosthesis

The course of 22 pregnancies in 11 women undergoing heart valve replacement with a porcine xenograft is reported. All of the pregnancies treated with warfarin were interrupted by induced abortion. Of the 11 pregnancies treated with dipyridamole which were not interrupted by induced abortion, fetal wastage occurred in five. There was no fetal wastage among three patients who were not treated by any kind of anticoagulant. A review of the literature revealed that fetal complications among patients with the mechanical prosthetic valve are significantly higher compared with patients with bioprosthetic valves. There was no maternal hemorrhagic or thromboembolic event in patients with bioprosthetic valves. Delivery after porcine xenograft insertion is safe provided that the patient is in good cardiac condition and does not require warfarin treatment.

Use of the Shaw Scalpel in pacemaker operations

Pacemaker carriers are at risk when undergoing operations involving the use of diathermy. The Shaw Scalpel utilizes a method by which the cutting edge of the blade is heated to a selected temperature that seals blood vessels as they are cut. No electrical currents are passed to or through the patient and there is no sparking or electrical arcing to the tissue. This apparatus was used as the sole method of thermal coagulation in 20 patients undergoing replacement of pacemaker batteries.

Isolation and characterization of metmyoglobin reductase from yellowfin tuna (Thunnus albacares)

The isolation, purification, and characterization of metmyoglobin reductase from yellowfin tuna (Thunnus albacares) is described. The enzyme has been purified 120-fold. Characterization of the enzyme includes molecular weight, isoelectric point, substrate specificity, enzyme kinetics, chromatographic behavior, and sensitivity to inhibitors. The physical and catalytic properties of the tuna enzyme are compared to those of bovine and blue-white dolphin metmyoglobin reductase.

Prosthetic valve replacement in infants and children

A review of 41 children from 10 months to 16 years of age who had a valve replacement between the years 1966 to 1981 is reported. Sixty-one per cent of the valve deformities were rheumatic and 39% congenital. Twenty-two children had the mitral valve replaced, 14 had an aortic valve and 5 had both aortic and mitral valve replacement. There was a hospital mortality of 9.7% and only one later death during a mean follow up period of 6.75 years. Three children have required a second mitral valve replacement. Thrombo-embolic episodes were encountered in 4 children. The special problems of valve replacement in infants and children are discussed.

CT diagnosis of left atrial thrombus undiagnosed by echocardiography

Although effectiveness of CT scan in the diagnosis of intracardiac masses is considered limited by heart pulsations, it may be effective in diagnosis of lesions not detected by echocardiography. This report presents a case where a large left atrial thrombus which was undiagnosed by 2D echocardiogram was diagnosed by CT scan.

Calcification of a porcine valve xenograft during pregnancy--a case report and review of the literature

A 20-year-old woman required urgent replacement of a calcified prosthetic mitral porcine xenograft with a mechanical one during the 32nd week of pregnancy. Five weeks later the patient delivered a normal child. Following delivery the patient refused oral anticoagulant treatment and 7 months later she underwent emergency removal of a prosthetic valve thrombus. Six months later, still refusing anticoagulant treatment, she died of cerebral embolization. We suggest that the replacement of a degenerated biologic valve with another biologic valve should be considered in patients who refuse anticoagulant treatment and that patients with prosthetic xenografts should be kept under close medical follow-up, including echocardiography because of possible accelerated xenograft failure during and/or following pregnancy.

Carcinoma of lung with a solitary cerebral metastasis. Surgical management and review of the literature

During the years 1975 to 1980, 10 male patients and 1 female, with ages ranging between 40 to 61 years, underwent combined resection of primary lung cancer and solitary brain metastasis. In 8 patients the lung cancer was diagnosed and treated first. In those patients, craniotomy for removal of a solitary brain metastasis was carried out 8 to 60 months (mean, 27 months) after excision of the lung tumor. In 3 patients, brain metastasis was diagnosed and treated first and lung excision followed, 2 to 4 weeks after craniotomy. The most common histologic type of the tumor was adenocarcinoma (63.6%). There were no operative deaths. Three patients survived less than 6 months after surgery and were considered as a failure of surgical treatment. Seven patients lived longer than 1 year and three of them are still alive with a follow-up period between 2 to 3 1/2 years after both operations. One of the patients underwent recently successfully second brain intervention for removal of recurrent histologically identical solitary brain metastasis and is well. Our results and those reported in literature encourage the combined surgical removal of primary lung cancer and a solitary brain metastasis.

A simple method for insertion of a left atrial catheter in congenital heart disease

A relatively simple and safe method is described for the insertion of a left atrial pressure line in patients undergoing operation for repair of congenital heart defects. This method has been utilized successfully in 12 patients undergoing repair of a ventricular septal defect and tetralogy of Fallot.

Two years experience with Medtronic-Hall prostheses in 75 patients with special reference to its thrombogenicity and hemolysis

Seventy-five patients received 80 Medtronic-Hall valve prostheses during a 24-month period at the Beilinson Medical Center. The mean age was 50 years and the majority of patients had rheumatic heart disease. All operations were elective. There were 4 early and 2 late deaths (8%). Four patients needed re-operation for paravalvular leaks, 3 of them survived the second operation and one patient with prosthetic valve endocarditis did not. One patient was re-operated on successfully because of a mycotic aneurysm in the ascending aorta. Mild subclinical hemolysis (elevated SLDH and reduced haptoglobin) was found in the majority of patients. Hemolysis was found to be significantly lower in type D 16 prostheses patients. Mild hemorrhagic complications occurred in 2 patients due to anticoagulant therapy. Three patients suffered from prosthetic valve endocarditis (PVE), 2 of them responded to prompt medical therapy. There were no thromboembolic episodes. Most surviving patients experienced marked postoperative improvement. Within the 24-month follow-up period, the Medtronic-Hall valve compared favorably with other disk or ball prostheses previously and currently used in our department.

Coarctation of the aorta in infancy

Twenty-five infants under 1 year of age (mean weight 3.4 kg) underwent repair of coarctation of the aorta between the years 1965 and 1982. Three patients had coarctation only, three had coarctation with patent ductus arteriosus (PDA), and 19 had associated intracardiac anomalies. Eleven patients underwent resection of the aorta and end-to-end anastomosis. Eight had subclavian flap arterioplasty, five had patch graft arterioplasty, and one had subclavian-to-aortic anastomosis. Additional procedures were performed on seven patients: banding of the pulmonary artery on one, repair of total anomalous pulmonary venous drainage on one, mitral valve replacement on one, aortic valvotomy on one, and aortic valvotomy plus pulmonary artery banding on one. Twenty-one survived the operation. All patients who died had associated intracardiac anomalies. The 21 survivors have been followed from 3 months to 13 years, with three late deaths that were associated with intracardiac anomalies. Five of the survivors underwent additional second operations: one had repair of the re-coarctation, one had replacement of the prosthetic mitral valve, one had aortic valvotomy, and two had pulmonary artery debanding and closure of a ventricular septal defect. Two of the 18 surviving patients have mild hypertension associated with a residual gradient. The others are in good health.