Thrombolysis for obstructed CarboMedics mitral valve prosthesis

Prosthetic valve thrombosis, a rare but fatal complication, can be successfully treated with tissue-type plasminogen activator and monitored by transthoracic and transesophageal echocardiography.

Optic internal urethrotomy under transrectal ultrasonographic guide and suprapubic fiberoscopic aid

Optic internal urethrotomy is the initial treatment of choice for most urethral strictures because of the relatively low morbidity and ease of accomplishment. However, the procedure is difficult and frustrating if a severe stricture or complete disruption of the urethra is encountered. Transrectal ultrasonography of the urethra offers good anatomical visualization, and defines the exact length and extent of bulbous and posterior urethral strictures, which could ensure a more accurate and aggressive incision of the stricture. Eleven patients (8 with posttraumatic and 3 with iatrogenic strictures) with complete obliteration of the bulbous and posterior urethra were successfully treated by optic internal urethrotomy with the aid of transrectal ultrasonography and a suprapubic fiberscope. After 1 year of followup, 5 of the 8 posttraumatic urethral strictures required further management, while the remaining patients had satisfactory results. Although the recurrence rate is high in the posttraumatic patients, transrectal ultrasound and the suprapubic fiberoscope afford a reliable and satisfactory aid during optic internal urethrotomy.

Separation of ischiopagus tripus conjoined twins

The authors report on their second experience of a successful separation of ischiopagus tripus conjoined twins. Particular emphasis is placed on the painful decision of sacrificing the only available leg to cover the infected wound after an unexpected complication in twin A. The twins' preoperative evaluation, separation surgery, and subsequent 16-month course are described.

Separation of thoracopagus conjoined twins. A case report

A pair of thoracopagus conjoined twins with a connection at the atrioventricular groove of both hearts and a huge conjoined liver were surgically separated. An aortopulmonary shunt was created for Twin B, a victim of complex congenital heart disease with hypoplastic right heart syndrome, who died 5 hours later. However, Twin A survived after prolonged endotracheal intubation and parenteral nutrition. He survived for 7 months, and went home, but finally died of sepsis. In reviewing 47 pairs of surgically separated thoracopagus conjoined twins, in 30 pairs of type A (Leachman's classification, completely separate hearts), 42 patients survived (70%); in 5 pairs of type B (atrial connection only), one patient survived (10%); in 9 pairs of type C (both atrial and ventricular interconnections), none survived; in 3 pairs of unknown type, 2 survived. Total survival rate of surgically separated thoracopagus conjoined twins was 47.9%. The survival rate was 38.2% in those operated in the neonatal period (n = 34) and 63.6% in those operated over 1 month of age (n = 44) (p = 0.016). In conclusion, thoracopagus conjoined twins are rare. Although its separation carries a high risk, especially in those with cardiac connection, this report confirmed that separation is still feasible under proper preparation and planning.

Hyperbilirubinemia after cardiac operation. Incidence, risk factors, and clinical significance

Three hundred and two consecutive patients who had undergone cardiac operation for various cardiac lesions were studied prospectively to evaluate the incidence, risk factors, and the associated mortality of postoperative hyperbilirubinemia after cardiopulmonary bypass. Concentrations of the serum total (conjugated and unconjugated) bilirubin, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, alkaline phosphatase, albumin, globulin, and serum haptoglobin were measured before the operation and again on the first, second, and seventh postoperative days. Postoperative hyperbilirubinemia was defined as occurrence of a serum total bilirubin concentration of more than 3 mg/dl in any measurement during the postoperative period. Logistic regression was done to identify possible risk factors for postoperative hyperbilirubinemia. Overall incidence of postoperative hyperbilirubinemia was 35.1%; the incidence of postoperative hyperbilirubinemia was higher in patients whose valves were replaced with mechanical prostheses than in those without prostheses (p < 0.00001). In patients with postoperative hyperbilirubinemia, 70% of the increase of total bilirubin on the first postoperative day came about from an increase in unconjugated bilirubin. Serum haptoglobin decreased significantly at the same time (p < 0.01). Development of the postoperative hyperbilirubinemia was associated with a higher mortality (5.6% versus 0.5%, p < 0.01) and higher frequency of use of intraaortic balloon counterpulsation, especially for patients in whom the highest postoperative total bilirubin occurred after the first 2 days. The numbers of valves replaced, preoperative right atrial pressure, and preoperative total bilirubin concentration are the significant risk factors that, in combination, correctly predict the occurrence of postoperative hyperbilirubinemia in 80% of the patients. We concluded that postoperative hyperbilirubinemia results mainly from an increase in unconjugated bilirubin and is associated with higher mortality, especially for patients in whom highest postoperative total bilirubin occurred late after operation. Patients with the higher preoperative right atrial pressure and total bilirubin level who then underwent multiple valve replacement procedures are at greater risk for development of postoperative hyperbilirubinemia.

Deoxyribonucleic acid flow cytometric study in pheochromocytomas and its correlation with clinical parameters

OBJECTIVES

To study deoxyribonucleic acid flow cytometry (DNA-FC) in pheochromocytomas and its correlation with clinical parameters.

METHODS

Fifty cases of pheochromocytomas of a total of 58 cases were studied for DNA-FC from archival paraffin-embedded tissue blocks and were correlated with clinical parameters (ie, size of tumor, benign or malignant pathologic type, vanillymandelic acid [VMA] level in 24 hour urine, age, sex, duration of symptoms, symptom scores).

RESULTS

A total of 19 cases were diploid while 31 cases (62%) showed DNA aneuploidy with 21 cases tetraploid. Four cases were malignant. All of them were tetraploid. However, among the 46 benign cases, 10 were aneuploid and 17 were tetraploid. All 19 cases with DNA diploidy were benign. The DNA-FC did not correlate with other clinical parameters in our study.

CONCLUSIONS

We confirmed a high incidence of DNA aneuploidy in pheochromocytomas. All malignant pheochromocytomas were tetraploid and all cases with DNA diploidy were benign. Long-term follow-up of all cases, especially those with DNA aneuploidy (including tetraploidy), is mandatory.

Haematological variations in pigs during experimental left ventricular assistance with a pulsatile impeller pump

Left ventricular assistance with a pulsatile impeller pump was performed on 5 pigs. The pump delivered the blood from the left atrium to the aorta. The by-pass flow was adjusted to 40% of the total flow. All of the haematological variations were measured every hour. The results demonstrated that the pulsatile impeller pump caused less erythrocyte but more platelet damage than the nonpulsatile impeller pump in some experiments by dogs. The free haemoglobin was unchanged but lactate dehydrogenase increased remarkably in 6 h. Compared with the same experiments of the pulsatile impeller pump in goats and roller pump in pigs, it seems that the pig erythrocytes have more endurance to shear stress than that of dogs and goats, and pig platelets are more sensitive to mechanical force than those of other animals. The chronic experiment of pulsatile impeller pump is now in the planning stage for further investigations.

Comparison of conventional and simultaneous compression-ventilation cardiopulmonary resuscitation in piglets

To determine the mechanism of cardiac output and hemodynamic changes during cardiopulmonary resuscitation (CPR), we performed 60 min of CPR using a mechanical resuscitator ("Thumper", MII, USA) in 20 piglets (13.7 +/- 1.2 kg) following cardiac arrest induced by intravenous injection of KCl. Conventional CPR (C-CPR), i.e., 60 external chest compressions (60 psi force, 3 cm deep, and 50% duration) and 12 ventilations (following every 5th compression, with peak airway pressure of 30 cmH2O) per minute, was performed in 10 piglets; and simultaneous compression and ventilation CPR (SCV-CPR), i.e., 60 external chest compressions of the same magnitude, simultaneously with 60 ventilations (with peak airway pressure of 60 cmH2O) per minute, was performed in the 10 other piglets. Cardiac output in C-CPR and SCV-CPR was maintained near 70% or more of baseline throughout the CPR. Systemic vascular resistance dropped to below 50% of baseline. Systolic, mean and diastolic arterial pressures were maintained above 70, 40, and around 20 mmHg, respectively, during the first 30 min of CPR. Central venous pressure rose after arrest and subsequent CPR to above 25 mmHg, and remained high in SCV-CPR, but declined thereafter in C-CPR. Aortic diastolic minus right atrial diastolic pressure was around 15 mmHg early in CPR and dropped to almost zero thereafter. Serial arterial blood gas analyses showed a significant deterioration after 20 min of SCV-CPR. All but one piglet in the SCV-CPR group died after 60 min of CPR. Postmortem examination revealed that pulmonary barotrauma was more extensive and severe in SCV-CPR than in C-CPR.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic drainage for the treatment of posttransplant lymphocele

Lymphocele following renal transplantation may be associated with ureteral obstruction, venous obstruction, venous thrombosis, infection and pain. Drainage of lymphocele is indicated when these complications arise or if the patient is symptomatic from the size and pressure of the lymphocele. Less invasive methods for the treatment of lymphocele, including simple needle aspiration, external drainage and sclerotherapy, are associated with an unacceptably high incidence of recurrence and complications. Internal drainage is the treatment of choice either via the retroperitoneal transplant incision or transperitoneally through abdominal incision. We now report a case of posttransplanted lymphocele that was successfully drained into the peritoneal cavity using laparoscopy. We believe this is an effective alternative route to provide internal drainage for lymphoceles.

Massive retroperitoneal hemorrhage from spontaneous rupture of a renal angiomyolipoma during pregnancy. A case report

We present the case of a 29-year-old, pregnant woman who, at 27 weeks' gestation, suffered an acute abdomen with hypovolemic shock that led to intrauterine fetal death in spite of an emergency laparotomy. The final diagnosis was ruptured renal angiomyolipoma, which caused a massive retroperitoneal hemorrhage.

Clinical experience of posterior urethral valves

Nine patients with posterior urethral valves were seen at Chang Gung Memorial Hospital from 1985 to 1992. The age at presentation ranged from five days old to 28 years old. The presenting symptoms and signs included abdominal distension, urinary tract infection, respiratory distress, urinary ascites, and weak stream. Patients were examined by voiding cystourethrography and ultrasonography. Surgical management of these patients included primary valve ablation (three cases), cutaneous vesicostomy plus delayed valve ablation (five cases) and primary valve ablation with delayed ureteral reimplantation (one case). For small infants with posterior urethral valves (five cases), temporary vesicostomy and delayed valve ablation offers excellent results in preventing iatrogenic urethral stricture. However, for older children and young adults, the recommended treatment is primary valve ablation. For seven patients with nadir serum creatinine < 1.0 mg/dL, the renal function remained within the normal range, yet during follow-up, one case had renal insufficiency. Vesicoureteral reflux was found in five cases. Spontaneous resolution was noted in two cases after valve ablation, and three cases were controlled with prophylactic antibiotics. The experience of our series suggests that primary valve ablation may be traumatic to the neonatal urethra and temporary diversion would allow greater renal recovery during the neonatal period. With newer delicate instruments, valve ablation may be performed earlier and as a one-stage operation in the future.

Traumatic asphyxia

Four patients showing classic physical stigmata of traumatic asphyxia were studied. Cervicofacial cyanosis and edema, subconjunctival hemorrhage, and multiple ecchymotic hemorrhage of the face, neck, and upper part of the chest were documented. Admission Glasgow coma scale scores ranged from 8 to 15. All but one had no associated injury. Skin discoloration resolved within 3 weeks. Complete resolution of subconjunctival hemorrhage occurred 1 month later. In our series, sore throat, hoarseness, dizziness, numbness, and headaches were common. Profound lower leg pitting edema, hemoptysis, hemotympanum, and transient visual loss were noted. Chest radiographic findings were normal in all patients. Microscopic hematuria was noted in one patient. Diagnosis is made from the history and characteristic appearance of the patient. Treatment is directed to the associated injury. Oxygen supplement with head elevation to 30 degrees is the mainstay of treatment. If the patient survives the initial insult, the prognosis is excellent.

In vivo evaluation of a pulsatile impeller total heart

For the in vivo evaluation of a pulsatile impeller total heart, biventricular assistance was performed in five pigs weighing 30-50 kg. The left pump delivered blood from the left atrium to the aorta, and the right pump from the right atrium to the pulmonary artery. The bypass flow on both sides was adjusted to about 40-50% of the total flow. Hematologic variables were measured every 2 hr during the 6 hr experiments. Results demonstrated that the pulsatile impeller total artificial heart causes no blood damage and can be used in chronic survival experiments.