Right ventricular outflow obstruction with intact ventricular septum in adults

Cardiothoracic surgeons whose practice is limited to adults rarely see patients with right ventricular outflow obstruction and an intact ventricular septum. Of more than 10,000 open-heart procedures performed at our institution from 1983 to 1993 (in patients 18 to 75 years old), only 5 procedures were for correction of this problem. Both the pulmonary valve and the subvalvular area were abnormal in these 5 patients, and 4 of the 5 had subvalvular stenosis. The gradient across the right ventricular outflow tract was measured by cardiac catheterization before repair in all patients and averaged 118 mmHg. Various surgical approaches were used for repair. In the 2 patients whose pressures were measured postoperatively, the gradients were 25 mmHg and 45 mmHg, respectively. There were no operative deaths. At follow-up (range, 2 months to 5 years after surgery), all patients were in New York Heart Association functional class I and all had murmurs. Those who underwent echocardiography were found to have minimal gradients across the right ventricular outflow tract.

Pneumonectomy for unremitting hemoptysis in unilateral absence of pulmonary artery

Unilateral absence of pulmonary artery is a rare malformation that can present as an isolated lesion or may be associated with other congenital heart defects. Clinical presentation is subtle when the lesion occurs alone, and may include hemoptysis, which results from rupture of abundant bronchial submucosal vessels perfused by enlarged systemic collaterals that supply the affected lung. Pneumonectomy is recommended as definitive treatment in such an adult patient.

Normothermic retrograde continuous cardioplegia for myocardial protection during cardiopulmonary bypass. A modified technique

Normothermic retrograde continuous cardioplegia is a revolutionary development for myocardial preservation in cardiac surgery. Despite excellent reports regarding this technique, the surgical community has expressed concern over technical problems encountered. The method of normothermic retrograde continuous cardioplegia in current use requires both large total crystalloid volumes and large potassium loads to deliver adequate cardioplegia. We have developed a technique that eliminates these problems. The heart is stopped by an initial infusion of normothermic cardioplegic solution through a coronary sinus catheter. The infusate is then converted to normothermic pump blood. Small boluses of potassium chloride are added intermittently to maintain cardiac arrest. We applied this technique to 35 patients undergoing cardiac valve surgery. The average volume of crystalloid cardioplegia required was 125 mL (range, 40 to 155 mL), and the average total potassium load was 52 mEq (range, 2 to 100 mEq). Clinically significant sequelae were noted in 4 patients (11%), and 1 (3%) died of pneumonia on the 28th postoperative day. The method we describe is a safe and effective alternative to the current technique of normothermic retrograde continuous cardioplegia and offers both physiologic and technical advantages to patients undergoing cardiac valve procedures.

Interlocking figure-of-8 closure of the sternum

Sternal dehiscence and mediastinitis are two of the most severe complications of a median sternotomy. A technique of closure is described that appears to provide a more stable sternal approximation without any increase in overall complication rate. Using this technique in 978 consecutive patients, no cases of sternal dehiscence or mediastinitis have been seen.

Contraindications for percutaneous transluminal coronary angioplasty in treatment of unstable angina pectoris

In recent years, the indications for percutaneous transluminal coronary angioplasty have expanded to include multivessel disease, unstable angina pectoris, stenosis of coronary bypass grafts, and recent total coronary occlusion. To evaluate our experience in using percutaneous transluminal coronary angioplasty to treat unstable angina, we reviewed the records of the patients who underwent this procedure at our hospital between January 1983 and December 1986. Of the 689 patients who underwent balloon angioplasty during the study period, 454 had stable angina and 235 had unstable angina; of the latter group, 34 (14.5%) required emergency coronary artery bypass grafting after balloon angioplasty failed. This outcome was associated with 2 risk factors: previous myocardial infarction and triple-vessel disease. Our data suggest that, in cases of unstable angina pectoris, percutaneous transluminal coronary angioplasty should be reserved for patients with single-vessel disease and no evidence of previous myocardial infarction. They also lend credence to the conclusion that the disease process in unstable angina is different from that in stable angina, and that therapy should be directed towards reducing platelet aggregation and correcting global ischemia, rather than towards balloon angioplasty of "culprit lesions."

Massive chylopericardium after coronary artery bypass surgery

Massive isolated chylopericardium is a rare postoperative complication of coronary artery bypass surgery. In the following case, massive chylopericardium developed after a coronary artery bypass procedure in which the left internal mammary artery was used for revascularization. The chylopericardium resulted from direct trauma to the thoracic duct during mobilization of the left internal mammary artery to its origin at the subclavian artery. With adequate drainage, the problem was resolved. In cases in which drainage persists, ligation of the thoracic duct may be necessary.

Ventricular septal defect due to nonpenetrating chest trauma: use of the intra-aortic balloon pump

Nonpenetrating traumatic ventricular septal defect is rare. A triad of blunt chest trauma, holosystolic precordial murmur, and ECG abnormalities should suggest the diagnosis. Surgical repair, when indicated by progressive failure, rising pulmonary artery pressures, or significant (2:1 or larger) left-to-right shunt, has been shown to be very effective. Optimally, a period of several weeks from the injury should elapse before operative intervention is undertaken. Intra-aortic balloon pump may be helpful to stabilize patients acutely, and, in selected instances, allow delay of surgical repair so that the tissue around the defect may hold sutures more securely.

Extended aortic root replacement with aortic allografts

Complex left ventricular outflow tract obstruction after operation for subaortic stenosis or with hypoplastic aortic anulus remains a challenge for pediatric cardiac surgeons. We have recently applied a new technique of extended aortic root replacement using a cryopreserved aortic allograft to treat two patients who had previously been operated on for subaortic stenosis and a third who had aortic stenosis with a hypoplastic aortic anulus. This new procedure combines the concept of aortoventriculoplasty with aortic root replacement and coronary artery reimplantation. The valved aortic homograft is used in place of an aortic valve prosthesis and the attached anterior mitral leaflet augments the interventricular septum to relieve the subvalvular left ventricular outflow tract obstruction. The coronary ostia are then reimplanted into the allograft and an anastomosis between the distal graft and the ascending aorta is completed. Allograft aortic tissue is then used to patch the right ventricular outflow tract. One patient had aortic stenosis with annular hypoplasia and did well after extended root replacement. Two patients had previous operations for subaortic stenosis before undergoing extended aortic root replacement. One required mediastinal exploration and drainage at 2 weeks for Serratia marcescens mediastinitis and bacteremia, but uncomplicated recovery followed. The other patient had complete heart block for 2 days, but normal sinus rhythm resumed and convalescence was benign. This modified technique with the aortic allograft was very helpful in treating these difficult problems, and the lack of mortality, limited morbidity, and good functional results are encouraging.

Peripheral vascular trauma from close-range shotgun injuries

This report summarizes an eight-year experience (1976 to 1983) with 49 close-range shotgun blasts with associated major vascular injuries seen in a large urban hospital. Injuries to the upper extremity (40%), lower extremity (56%), and neck (4%) were seen. A high frequency of associated deep venous injury (82%), nerve injury (37%), fracture (33%), massive soft-tissue loss (43%), and compartmental hypertension (39%) was observed. There were no deaths in this series, and the limb salvage rate was 96%. Neither patient with multiple carotid artery injuries suffered a neurologic deficit. We attribute our success in the management of these complex injuries to rapid fracture immobilization, early and aggressive use of fasciotomy, adequate débridement of devitalized tissue, repair of deep venous injuries, arterial repair with autogenous tissue, and extra-anatomic bypass grafting in selected cases.

Adventitial cystic disease of the popliteal artery

Adventitial cystic disease of the popliteal artery is an unusual condition of uncertain etiology in which a mucin-containing cyst forms in the wall of the popliteal artery and causes symptoms of intermittent claudication, typically in young adults whose arteries are otherwise normal. Arteriography characteristically shows a smooth-walled, curvilinear narrowing. In the case described, a combination of findings from arteriography, computed tomography, and ultrasound resulted in a highly specific preoperative diagnosis.

Severe thoracic and abdominal injuries associated with lap-harness seatbelts

We report an unusual constellation of severe thoracic and abdominal injuries in a passenger restrained by a lap-harness seat belt during a high-speed automobile accident. This combination of injuries, which appears to have not previously been described, emphasizes the causative relationship of this protective device.

Inflammatory polyposis in an ileal blind loop

A case of inflammatory polyposis of the ileum after ileosigmoid anastomosis is reported. Two features are noteworthy. First, the polyps were localized in a blind ileal loop. Second, while rare ileal inflammatory polyps related to enteroenteric anastomosis have been reported, to our knowledge this is the first instance of approximately 50 polyps to be described at such a site. The etiology of these lesions is unknown but may be related to fecal irritation, stasis, bacterial overgrowth, or bacterial toxin. These polyps may ulcerate and bleed, causing iron deficiency anemia, and they must be distinguished from neoplastic polyps. Since side-to-side and end-to-side anastomoses have become more common with use of the surgical stapler, inflammatory polyps may be encountered more frequently.