Cardiac angiosarcoma: an unusual presentation simulating mitral stenosis and constrictive-effusive pericarditis

This case report details a patient with a cardiac angiosarcoma who had an unusual presentation with hemodynamics consistent with mitral stenosis and constrictive-effusive pericarditis. It illustrates how transesophageal echocardiography adds to the information obtained from transthoracic imaging and hemodynamics in this unusual presentation of a cardiac tumor.

Deceleration time in ischemic cardiomyopathy: relation to echocardiographic and scintigraphic indices of myocardial viability and functional recovery after revascularization

BACKGROUND

In patients with heart failure secondary to left ventricular (LV) systolic dysfunction, a short deceleration time (DT) successfully predicts clinical outcome. The impact of myocardial viability and revascularization on the mitral inflow velocities, however, is unknown.

METHODS AND RESULTS

Forty patients with ischemic cardiomyopathy underwent (201)Tl scintigraphy (SPECT) and 2D, Doppler, and dobutamine echocardiography (DE, to 40 microg. kg(-1). min(-1)) 2 days before CABG. Echocardiography was repeated 3 months after revascularization to determine recovery of function. Significant correlations were present between DT and LV contractile reserve by DE (r=0.72), scar perfusion defect by SPECT (r=-0.69), and the change in ejection fraction (DeltaEF) after surgery (r=0.77) (all P:<0.01). DT >150 ms effectively identified (sensitivity 79%, specificity 81%) patients with DeltaEF >/=5%. The population was divided into 2 groups according to DT: group 1 (DT >150 ms, n=21) and group 2 (DT </=150 ms, n=19). At baseline, NYHA class, LV EF, age, and use of cardiovascular drugs were similar between the 2 groups. The number of viable segments by both DE and SPECT, however, was higher in group 1 (both P:<0.01), and only patients in group 1 had an increase in EF (29+/-4.8% to 40+/-8%, P:<0.01) after surgery. Death and heart transplantation occurred in 7 patients from group 2 and 1 patient from group 1 (P:=0.017).

CONCLUSIONS

In patients with ischemic cardiomyopathy, the reduced amount of viable myocardium results in a restrictive mitral inflow pattern, which in turn predicts poor survival.

Altered adrenergic receptor density in myocardial hibernation in humans: A possible mechanism of depressed myocardial function

BACKGROUND

Alterations in adrenergic receptor densities can potentially contribute to myocardial dysfunction. Their relevance to myocardial hibernation in humans is unknown.

METHODS AND RESULTS

Accordingly, 22 transmural myocardial biopsies were obtained in 11 patients with ischemic ventricular dysfunction during bypass surgery, guided by transesophageal echocardiography. Patients underwent dobutamine echocardiography (DE) and rest scintigraphic studies before revascularization and DE at 3 to 4 months. alpha- and ss-receptor density (ARD and BRD) and extent of fibrosis were quantified from the myocardial biopsies. Of the 22 segments, 16 had abnormal rest function and 6 were normal. Severely hypokinetic or akinetic segments showed a 2.4-fold increase in ARD with a concomitant 50% decrease in BRD compared with normal segments. An increase in ARD, a decrease in BRD to a lesser extent, and thus an increase in ARD/BRD ratio were seen in dysfunctional segments with contractile reserve compared with normal segments and were most pronounced in those without contractile reserve (P:<0.001). Similar findings were observed if recovery of function or scintigraphic uptake was analyzed as a marker for viability. No significant relation between either ARD or BRD and percent myocardial fibrosis was noted (r=0.37 and -0.39, respectively).

CONCLUSIONS

Thus, graded and reciprocal changes in alpha- and ss-adrenergic receptor densities occur in viable, hibernating myocardium and may account in part for the observed depression in resting myocardial function and preserved contractile reserve in this entity.

Relation of tissue Doppler derived myocardial velocities to myocardial structure and beta-adrenergic receptor density in humans

OBJECTIVES

We sought to evaluate the relation of segmental tissue Doppler (TD) velocities to both the regional amount of interstitial fibrosis and the myocyte beta-adrenergic receptor density in humans.

BACKGROUND

The systolic myocardial velocity (Sm) and early diastolic myocardial velocity (Em) acquired by TD are promising new indexes of left ventricular function. However, their structural and functional correlates in humans are still unknown.

METHODS

Ten patients with coronary artery disease underwent echocardiographic examination including TD imaging, along with transmural endomyocardial biopsy at the time of coronary bypass surgery (two biopsies per patient for a total of 20 specimens). The specimens were analyzed for percent interstitial fibrosis and beta-adrenergic receptor density.

RESULTS

Normal segments (n = 8) had a higher beta-adrenoceptor density (2,280 +/- 738 vs. 1,373 +/- 460, p = 0.03) and a lower amount of interstitial fibrosis (13 +/- 3.3% vs. 28 +/- 11.5%, p = 0.002) than dysfunctional segments (n = 12). Myocardial systolic velocity and Em were also significantly higher (9.5 +/- 2.7 vs. 5.9 +/- 1.8 cm/s, p = 0.025 and 11.3 +/- 2.8 vs. 6.4 +/- 2.1 cm/s, p = 0.002, respectively) in normal segments. A significant relationship was present between Em and the beta-adrenergic receptor density (r = 0.78, p < 0.001) and percent interstitial fibrosis (r = -0.7, p = 0.0026), which together accounted for 81% of the variance observed in Em. Likewise, a significant relationship was present between Sm and the beta-adrenergic receptor density (r = 0.68, p < 0.001) and the percent interstitial fibrosis (r = -0.66, p = 0.004) and together accounted for 62% of the variance observed in Sm.

CONCLUSIONS

Systolic myocardial velocity and Em are strongly dependent on both the number of myocytes and the myocardial beta-adrenergic receptor density.

Relation of the contractile reserve of hibernating myocardium to myocardial structure in humans

BACKGROUND

Although dobutamine echocardiography (DE) is widely used to assess myocardial viability in humans, little is known about the relation between contractile reserve and myocardial structure.

METHODS AND RESULTS

We evaluated 20 patients with coronary disease (64+/-13 years old, ejection fraction 28+/-7.5%) with DE (up to 40 micrograms . kg(-1). min(-1)), rest-redistribution (201)Tl single photon emission CT, and quantitative angiography before bypass surgery. During surgery, patients underwent transmural myocardial biopsies (n=37) guided by transesophageal echocardiography to determine the extent of interstitial fibrosis and intracellular and interstitial proteins by histopathology and immunohistochemistry. Among the 37 segments biopsied, 16 recovered function as assessed 2 to 3 months later. Segments with postoperative functional recovery had more wall thickening at low-dose DE (28% versus 3%, P<0.001), higher thallium uptake (69% versus 48%, P=0.03), and less interstitial fibrosis (2% versus 28%, P<0.001). Quantitative angiographic parameters did not predict recovery of function. Segments with DE viability (contractile reserve and/or ischemia) had less fibrosis (2.7% versus 28%, P<0.001), less vimentin and fibronectin (both P<0.01), more glycogen (P=0.016), and higher thallium uptake (64% versus 35.5%, P<0.05) than those without viability. Viable segments by both DE and thallium had less fibrosis (1%) than those viable by 1 of the 2 techniques (9%) or not viable by both (28%, P=0.005). Thickening at low-dose DE correlated well with the extent of interstitial fibrosis (r=-0.83, P<0.01).

CONCLUSIONS

Contractile reserve during DE correlates inversely with the extent of interstitial fibrosis and the amount of fibronectin and vimentin and directly with rest-redistribution thallium uptake.

Combined carotid endarterectomy and coronary artery bypass: immediate and long-term results

Data from 213 cases of simultaneous carotid endarterectomy and coronary artery bypass grafting (CEN/CABG) were analyzed (1980-1996). There were 154 males (72.3%), and 59 females (27.7%), (mean age: 65. 6 years, range: 42-83). One hundred and thirty-two patients (62.0%) had angina, 58 (37.2%) had myocardial infarction, and 23 (10.8%) had congestive heart failure. Symptomatic cerebrovascular disease was present in 89 patients (41.7%). One hundred and twenty-two patients (57.2%) had three-vessel coronary artery disease, 41 (19.2%) had left main disease, and 27 (12.6%) had a low ejection fraction (ejection fraction </=30%). Significant (>/=75% diameter reduction) stenosis was present in 168 (78.8%) of the operated carotid arteries. The contralateral internal carotid artery was severely stenosed or occluded in 35 patients (16.4%). The hospital mortality rate was 5. 6% (12 patients). The cause of death was cardiac in ten patients (4. 6%), and neurologic in two (1%). Eleven patients (5.1%) developed a stroke postoperatively; eight strokes were ipsilateral to the operated artery, and six were permanent. Myocardial infarction occurred in five patients (2.3%). Independent predictors of early mortality were age >62 years, hypertension, and postoperative stroke (p < 0.05). Male sex was the only independent predictor of neurologic morbidity (p < 0.05). Late follow-up data were obtained for 163 (81.0%) patients (mean: 54.8 months, range: 1-168). Four (9. 3%) out of the 43 late deaths were attributed to strokes. There were three (1.8%) late ipsilateral strokes, and five (3.1%) contralateral strokes. The 5- and 10-year survival probabilities were 75 +/- 4%, and 52 +/- 6.9%. The freedom from late ipsilateral neurologic morbidity at 5 and 10 years were 97 +/- 1.7% and 90 +/- 4.0%, respectively. Taken together, the results indicate that combined carotid endarterectomy and coronary artery bypass grafting can be performed safely in this high-risk group of patients. Excellent long-term freedom from stroke can be expected.

Assessment of myocardial viability with 99mTc-sestamibi tomography before coronary bypass graft surgery: correlation with histopathology and postoperative improvement in cardiac function

BACKGROUND

Assessment of myocardial viability by 99mTc-sestamibi remains controversial. Accordingly, we investigated the use of sestamibi as a marker of myocardial viability, defined by histopathology, and for predicting improvement of myocardial function after coronary artery bypass graft surgery (CABG).

METHODS AND RESULTS

99mTc-sestamibi perfusion tomography and radionuclide angiography were performed within 2 days before CABG in 21 patients with > or = 75% stenosis of the left anterior descending coronary artery and resting anterior wall dyssynergy. During CABG, transmural myocardial biopsies were obtained from the dyssynergic anterior wall and from normal myocardial segments to determine the extent of viable myocardium by histopathology. Improvement of regional left ventricular function was evaluated by radionuclide angiography at 6 to 8 weeks after CABG. There was a good correlation (r=.85, P<.001) between the quantified sestamibi activity and the extent of viable myocardium determined morphometrically. Among 21 biopsied dyssynergic myocardial segments, 11 improved their function after CABG and 10 failed to improve. Biopsied segments with improved postoperative function had significantly higher sestamibi activity (81+/-5% versus 49+/-16%, P<.0001) and significantly lower extent of interstitial fibrosis (7+/-4% versus 31+/-21%, P=.0002) than segments that failed to improve. A 55% threshold of 99mTc-sestamibi activity had positive and negative predictive values of 79% and 100%, respectively, for recovery of function after CABG in the biopsied segments.

CONCLUSIONS

Myocardial 99mTc-sestamibi activity correlates well with the extent of viable myocardium and predicts improvement in regional function after CABG. This lends support to the use of sestamibi as a myocardial viability agent.

Thoracoabdominal fenestration for aortic dissection with ischemic colonic perforation

Previous attempts at repair of aortic dissection complicated by intestinal infarction requiring concomitant bowel resection have been fatal. Presented is a case of distal aortic dissection resulting in colonic infarction and perforation. Thoracoabdominal aortic fenestration with concomitant right hemicolectomy was successful. In patients with aortic dissection complicated by mesenteric ischemia, we recommend urgent graft replacement of the thoracoabdominal aorta when feasible. When peritoneal contamination precludes the use of prosthetic grafts, thoracoabdominal fenestration is an effective option.

Continuous electroencephalographic monitoring and selective shunting reduces neurologic morbidity rates in carotid endarterectomy

PURPOSE

The role of continuous electroencephalographic (EEG) monitoring during carotid endarterectomy was evaluated in this retrospective review.

METHODS

We analyzed data from 902 consecutive carotid endarterectomy procedures performed with vein patch angioplasty. In 591 operations from 1980 to 1988 we did not use intraoperative EEG monitoring or shunting (non-EEG group). Continuous intraoperative EEG monitoring and selective shunting were used in 311 procedures from 1988 to 1994 (EEG group). The patients' mean age was higher in the EEG group (68.8 years; range, 41 to 87 years) than in the non-EEG group (66.2 years; range, 34 to 90 years; p < 0.001). There was also a significantly higher incidence of hypertension (56.2% vs 41.9%) and redo operations (5.4% vs 2.54%) in the EEG group than in the non-EEG group (p < 0.05). The operative technique was identical in both groups. We defined a significant EEG change as a greater than 50% reduction of the amplitude of the faster frequencies, a persistent increase of delta activity, or both.

RESULTS

In the EEG group, acute EEG changes occurred in 40 patients (12.8%); 31 (77.5%) unilateral and ipsilateral to the operated carotid artery, and nine (22.5%) bilateral. In five patients (12.5%) the changes correlated with an intraoperative episode of hypotension, and after normal blood pressure was restored the EEG returned to normal. In 35 procedures (87.5%) a carotid shunt was inserted. In 33 of those patients the EEG returned to baseline, in one patient there was a significant improvement, and in one patient the EEG changes persisted. Postoperative hospital strokes occurred in one patient (0.32%) in the EEG group and in 13 patients (2.19%) in the non-EEG group (p < 0.05). All strokes (n = 14) were ipsilateral to the operated carotid artery. Of the 13 strokes in the non-EEG group nine were major and four were minor. The one stroke in the EEG group was embolic in origin and occurred before carotid cross-clamping; it was associated with profound EEG changes that did not reverse after placement of a shunt. In the total group (n = 902), intraoperative EEG monitoring was inversely associated with postoperative stroke (p < 0.05).

CONCLUSION

The overall neurologic morbidity rate was significantly lower in the EEG group than in the non-EEG group, therapy demonstrating the value of intraoperative EEG monitoring in carotid endarterectomy.

Carotid endarterectomy with homologous vein patch angioplasty: a review of 1006 cases

PURPOSE

Because homologous vein is rarely used in vascular reconstructions, we evaluated the homologous vein as a patch for the reconstruction of the carotid bifurcation after endarterectomy.

METHODS

Excess vein harvested during open heart operations was either refrigerated in saline solution or cryopreserved in a solution of 10% dimethyl sulfoxide. Donors were tested for transmissible infections, and the veins were cultured for common pathogens. Data were analyzed from 837 consecutive patients (1006 cases) who underwent carotid endarterectomy with homologous vein patch angioplasty between 1981 and 1993.

RESULTS

The perioperative mortality rate was 0.8% (eight patients). Two deaths (0.2%) were attributed to ipsilateral strokes. Ischemic strokes occurred in 12 patients (1.2%; 10 ipsilateral), and ipsilateral transient ischemic attacks occurred in three patients (0.3%). Follow-up data were obtained for 482 patients (56%; mean follow-up time, 61 months; range, 1 to 132 months). Ipsilateral recurrent symptoms occurred in eight patients (1.7%; seven strokes, one transient ischemic attack). Of the 63 late deaths (13%), the majority (25 patients; 40%) were caused by complications of coronary artery disease. The 10-year overall survival rate was 76% +/- 3.2%, and the 10-year rate of freedom from late ipsilateral morbidity was 96% +/- 1.4%. The 10-year rate of freedom from late stenosis (a reduction in diameter of > or = 20%) in the 220 arteries (22%) that were studied by duplex scan was 84% +/- 2.3%.

CONCLUSIONS

The postoperative mortality and neurologic morbidity rates of carotid endarterectomy with homologous vein patch angioplasty are similar to those in the best series with all types of closure. The existing long-term follow-up data indicate that the homologous vein is a durable patch that behaves like other patches used in the same location.

Ruptured ovarian artery aneurysm complicating a term vaginal delivery

Ruptured ovarian artery aneurysm is rare. Of the eight cases previously reported, seven were diagnosed postpartum. Our case of a ruptured right ovarian artery aneurysm was associated with massive retroperitoneal bleeding. The probable time of rupture could be traced to the second stage of labor. This case indicates the need for early evaluation of atypical flank pain during labor.

The St. Jude valve prosthesis: analysis of the clinical results in 815 implants and the need for systemic anticoagulation

Between July 1979 and December 1984, 785 patients received 815 St. Jude Medical valve prostheses. Valve-related mortality in the follow-up period was due to thromboembolism in seven cases, anticoagulant-related hemorrhage in three and perivalvular leak in two. Freedom from valve-related death or reoperation at 3 years was 96.4% for aortic valve replacement and 98.3% for mitral valve replacement. The overall rate of thromboembolism was 2.6%/patient-year with warfarin, 9.2%/patient-year with antiplatelet medication and 15.6%/patient-year in patients with no anticoagulant therapy. One episode of thrombotic obstruction of a mitral valve, in a patient receiving no anticoagulant therapy, resulted in an occurrence rate of such obstruction of 0.22%/patient-year. Valve replacement with the St. Jude valve produced excellent clinical results, but long-term anticoagulation with warfarin was required to minimize thromboembolic complications. The use of antiplatelet agents alone provided inadequate protection.

Operative and long-term results of staged contralateral carotid endarterectomy: a personal series

The operative risks as well as the proper interval for patients undergoing staged contralateral carotid endarterectomies remain uncertain. The long-term incidence of stroke after bilateral carotid endarterectomy is also poorly documented. In this report the results of staged contralateral carotid endarterectomies performed by one surgeon in a consecutive series of 89 patients are analyzed. No deaths occurred after a first or contralateral carotid endarterectomy. Four (4%) neurologic deficits (three minor and one major) occurred after a first operation, whereas only one (1%) major neurologic deficit occurred after a contralateral carotid endarterectomy. Postendarterectomy hypertension was noted in 33 (37%) patients after a first operation, and in 62 (70%) patients after a contralateral carotid endarterectomy (p less than 0.00001). No correlation existed among the intervals between carotid operations and the incidence or duration of hypertension after a contralateral carotid endarterectomy. From our results we conclude that the staged contralateral carotid endarterectomy can be safely performed with a stroke-mortality rate approaching 1%. Postendarterectomy hypertension, although more frequent after the contralateral operation as compared with the first operation, has no correlation with the interval between procedures. After a staged bilateral carotid endarterectomy, only one (1%) patient experienced transient ischemic attack symptoms, but five (6%) patients suffered late stroke (four fatal).

Pulmonary scar carcinoma. A case with two primaries

The presence of scar tissue associated with peripheral pulmonary carcinomas has always evoked considerable interest. This report concerns a unique case of a 55-year-old white oil-field worker whose right pneumonectomy specimen disclosed two primary pulmonary scar cancers, involving both upper and lower lobes. Both carcinomas arose at the margins of pleural-based scars. The malignancy in the right upper lobe was a 2.5-cm large cell carcinoma, while that in the right lower lobe was a 2.0-cm adenocarcinoma. The bronchial and hilar lymph nodes were free of metastases. One month following pneumonectomy the patient suffered a cardiac arrest, and necropscopic examination failed to reveal evidence of metastases. Controversy continues concerning whether the scar precedes or follows the development of peripheral pulmonary carcinomas. Several recent studies favoring the latter theory have suggested that the scar is immunologically related to the carcinoma. In the current case, the pleural-based upper lobe scar was associated with an old, inactive granuloma, while the lower lobe pleural-based scar disclosed no clue as to its origin. The adenocarcinoma in the lower lobe might possibly be immunologically related to its associated scar; however, it would appear difficult to account for the scar of the upper lobe large cell carcinoma by a similar mechanism.

Perforation of the pulmonary artery with Swan-Ganz catheters: diagnosis and surgical management

Swan-Ganz catheters have become a very valuable and frequently used method of monitoring hemodynamics in sick patients. Although the incidence of complications is very low, more reports are beginning to appear. One of the more serious complications is the rupture of the pulmonary artery. This report concerns three patients who had a rupture of the pulmonary artery who survived, including one of almost fatal exanguination. A literature review of all cases of pulmonary artery rupture is presented. Fifty-three per cent (8/15) were fatal. Emphasis is placed on the prevention of this by using the guidelines. Discussion also covers possible contributing causes and treatment. A high index of suspicion is necessary whenever a patient with the catheter has hemoptysis or unexplained cardiac or respiratory changes.

Porcine heterograft valve replacement in carcinoid heart disease

A 53-year-old man with a pancreatic carcinoid tumor and liver metastases had the carcinoid syndrome with involvement of the tricuspid valve by carcinoid plaque. The mitral valve was involved by unrelated myxomatous degeneration (floppy valve). Each valve was replaced by a Hancock glutaraldehyde-prepared porcine heterograft prosthesis. When the patient died of complications of the tumor 8 months postoperatively, both valves had clinically normal function. Nevertheless, the carcinoid plaque, which was present in all four cardiac chambers and almost completely covered the endocardial surfaces of both atria, extended onto both prostheses. This eventually might have interfered with prosthetic valve function.

Clinical experience with the Smeloff-Cutter prosthesis: 1- to 12-year follow-up

To determine the long-term results of aortic valve replacement with the Smeloff-Cutter prosthesis, the fate of 358 of 459 (78%) consecutive patients was determined 1 to 12 years postoperatively. There were 319 male patients (70%). Mean age at operation was 57 years (range, 15 to 84 years). Aortic stenosis was the dominant lesion in 267 patients (58%) and aortic regurgitation in 133 patients (29%). Fifty-nine patients (13%) had both aortic stenosis and regurgitation. In addition to aortic valve replacement, 93 patients (20%) had coronary artery bypass, 30 (6.5%) had mitral commissurotomy, 23 (5%) had mitral valve replacement, and 41 (9%) had other procedures. Preoperative status by New York Heart Association Functional Class was: Class I, 3 (1%); Class II, 39 (8%); Class III, 148 (32%); and Class IV, 269 (59%). Operative (30-day) mortality was 8.5% (39 out of 459). Functional improvement was obtained in all postoperative survivors: 345 (82%), Class I; 63 (15%), Class II; and 12 (3%), Class III. A perivalvular leak developed in 6 patients (1%) and subacute bacterial endocarditis in five (1%). Actuarial long-term survival was 80% at 5 years and 71% at 8 years. Thromboembolism occurred in 34 patients (9.5%). The incidence of thromboembolism per 100 patient-years for patients receiving no anticoagulants was 5.4; antiplatelet agents, 2.9; and Coumadin (sodium warfarin), 2.6. Major thromboembolism was uncommon in patients on a regimen of sodium warfarin but major morbidity from bleeding was significant.

Results of epicardial pacing by the left subcostal approach

We have determined the clinical course of 200 consecutive patients (mean age, 67.5 years) in whom epicardial pacing was established by the left subcostal route by insertion of 2 sutureless myocardial electrodes and a demand bipolar generator. There was 1 intraoperative death (0.5%). The overall 30-day perioperative mortality was 4 of 200 patients (2.0%). The principal postoperative complications included postpericardiotomy syndrome in 8 patients (4.0%), pneumonia or marked atelectasis in 2 patients (1.0%), and pulmonary embolus in 1 patient. Hemiplegia developed in 2 patients at 9 and 10 days, respectively, after operation, and transient monoparesis developed in another patient (1.5%). There were no wound infections, but the one wound dehiscence required resuturing. Follow-up has been completed in all patients from 1 to 39 months postoperatively (mean, 14.9 months). There have been 21 late deaths. Late lead thresholds were recorded for 45 individual leads from 26 patients up to 35 months after operation. The results obtained indicate that for patients undergoing primary implantation, the sutureless myocardial electrode provides reliable lead function. However, patients who required reoperation because of previous pacemaker failure due to threshold rise have done poorly as a group and may be better managed with lithium high-output pacemaker generators.

Improved results of operation for ruptured abdominal aortic aneurysms

Of 1,393 consecutive patients operated on for aneurysm of the abdominal aorta between 1964 and 1978, 61 consecutive patients had undergone emergency operation for ruptured abdominal aortic aneurysm, for an incidence of 4.4% (61 of 1,393). There were 57 men and four women; their mean age was 77.5 years, with a range of 49 to 93 years. In 21 patients the diagnosis of aneurysm had been known from 1 day to 5 years prior to rupture. Hypotension (less than 100 mm Hg systolic) was present in 27.9% of patients (17 of 61) on admission to hospital and prior to operation in a total of 44.3% patients (27 of 61). Operation was begun in eight patients with an initially unrecordable blood pressure. The perioperative mortality rate (30 day) was 14.8% (nine of 61). The two factors most influencing survival were age [no patient younger than 60 years died vs. 40% of patients (four of 10) older than 80 years] and the magnitude of blood loss (survivors lost a total of 4,513 ml vs. 8,500 ml in those who died). Thus the most common cause of death was myocardial infarction (six of eight) in elderly patients, secondary to poorly tolerated severe hypovolemia. The results of this study suggest the need for avoidance of technical problems during operations, earlier referral of patients with known abdominal aortic aneurysms, especially the elderly, and early diagnosis with immediate operation for ruptured aneurysms.

Improved results of carotid endarterectomy in patients with symptomatic coronary disease: an analysis of 1,546 consecutive carotid operations

The significant risk of fatal myocardial infarction after carotid endarterectomy in patients with coronary disease long has been recognized. In 1,546 consecutive carotid endarterectomies performed in 1,238 patients over the last 10 years, angina pectoris was present in 17% (212/1,238) of patients; a further 32% (396/1,238) of patients were asymptomatic, but had a history of myocardial infarction. The perioperative mortality (30 day) in the 1,306 consecutive endarterectomies in 1,026 patients without symptomatic coronary artery disease was 1.5% (15/1,026 patients). Of the 212 patients with symptoms, 85 carotid endarterectomies were performed in 77 patients without prior coronary bypass operation with an operative mortality of 18.2% (14/77 patients). The remaining 135 patients had 155 carotid endarterectomies but were treated by either prior coronary artery bypass (84 patients) or simultaneous carotid endarterectomy and coronary artery bypass (51 patients) with an operative mortality of 3% (4/135 patients). The greatly improved survival in those patients with symptomatic coronary disease who had a coronary artery bypass prior to or at the same time as carotid endarterectomy, and the absence of permanent neurological deficit in the 51 of these 135 patients who had simultaneous carotid endarterectomy and coronary artery bypass suggests that significantly improved survival can be achieved after carotid endarterectomy in these high risk patients by the use of simultaneous coronary artery bypass surgery.

Fortuitous rupture of aortic aneurysm: a catastrophic event affording time for surgical cure

The rupture of an aortic aneurysm is generally a fatal event, but occasionally the rupture will occur into an adjacent vascular structure, thereby preventing exsanguination and affording temporary survival. Three cases are presented illustrating the fortuitous nature of the rupture of an aortic aneurysm into a vascular structure. The first patient had an atherosclerotic abdominal aortic aneurysm that ruptured into the inferior vena cava and was successfully repaired. The second case demonstrates the formation of a fistula from the aorta to the left pulmonary artery in a patient with a syphilitic thoracic aortic aneurysm. In the third patient a dissecting aneurysm of the aortic root that communicated with the right ventricle after coronary bypass surgery was successfully repaired. Rarely, aortic aneurysms will rupture fortuitously into vascular capacitance structures. These three cases emphasize the need for early accurate diagnosis and the institution of appropriate surgical measures.

Operative risk in patients with previous coronary artery bypass

Noncoronary operations were performed in 358 patients who had undergone a previous coronary artery bypass grafting, with a mortality of 1.1%. In 70 patients (20%), the staged operation was planned and subsequent operation performed 6 to 12 weeks after bypass with no cardiac complications and 1 death. In the others, operation was performed 10 days to 89 months after bypass for either urgent reasons or new lesions. Three deaths and significant numbers of medical cardiac complications occurred in those patients subjected to operation within 30 days. The subsequent operation was vascular in 232 patients, with 3 deaths (1.3%); thoracic in 43, with no deaths; and general surgical in 113, with 1 death (0.9%). Follow-up study showed 307 patients (87%) still alive after 30 days to seven years. Late death was due to myocardial infarction in only 12 patients (3%). This study suggests that the risk of operation is as good in patients who have had successful coronary artery bypass as in those without coronary artery disease, and that the risk of subsequent myocardial infarction is small.

Aneurysm of the sinus of Valsalva producing obstruction of the left main coronary artery

An aneurysm of the left sinus of Valsalva compressed the left main coronary artery and the patient experienced anginal pain. Surgical correction consisted of obliteration of the orifice of the aneurysm, aortic valve replacement, and a saphenous vein bypass from the ascending aorta to the distal left anterior descending coronary artery. Postoperative studies revealed excellent function of the prosthetic valve, no recurrence of the aneurysm and retrograde filling of the left anterior descending and circumflex coronary arteries. Three years after the operation, the patient is asymptomatic.

Left subcostal insertion of the sutureless myocardial electrode

This report describes the use of a left subcostal extrapleural supradiaphragmatic approach to the heart for myocardial sutureless electrode insertion. Electrode insertion by this approach has consistently produced low electrode thresholds, and the ability to insert electrodes into the left ventricle or septal area of the right ventricle is considered an advantage. This technique has now been used in 52 patients. Postoperative morbidity and complications have been minimal. The procedure appears to be well tolerated in the elderly, poor-risk patient and has been a useful technique for revision of failed pacemaker systems. We believe this procedure reduces the indications for permanent transvenous pacing.

Aneurysm of the main pulmonary artery: long-term survival after aneurysmorrhaphy and closure of a ventricular septal defect

Pulmonary artery aneurysm (PAA) usually carries an ominous prognosis due to the associated pulmonary hypertension. Six years ago a patient with a PAA secondary to cystic medial necrosis and pulmonary hypertension due to a ventricular septal defect (VSD) was treated by aneurysmorrhaphy and closure of the VSD. Although the patient had early postoperative cardiac failure, his cardiopulmonary status stabilized, and he has done well without recurrence of his aneurysm or cardiac failure. This report summarizes the patient's clinical course, operative treatment, and long-term follow-up.

Successful partial excision of an intramural fibroma of the left ventricle

A report of the only surviving adult to undergo partial excision of an intramural cardiac left ventricular fibroma is presented. Good results were obtained by relieving outflow tract obstruction through partial excision of the tumor from the septum and left ventricle. The need for conservative surgical treatment of patients with this rare, benign tumor is emphasized.

Emergency coronary artery bypass grafts in the treatment of myocardial infarction

Of the more than 1,900 patients undergoing coronary artery bypass procedures for coronary artery disease, a selected group of 17 patients underwent emergency coronary artery bypass because of the tentative diagnosis of acute myocardial infarction. Almost all patients had status angina prior to cardiac catheterization as was proven by electrocardiographic evidence and serum enzyme changes. When further verification was obtained by gross examination at surgery and autopsy in the patients who expired, most patients had severe end stage coronary artery disease manifested by functional classification and severe anatomical lesions. Cardiac catheterization was done in all patients prior to myocardial infarction. Because of the combination of pre-existing severe anatomical disease and status angina, coronary artery bypass surgery was done despite the presence of acute myocardial infarction in the three groups of patients. Group I consisted of patients with myocardial infarction without hypotension but persistent chest pain and clinical symptoms. Group II patients had similar findings plus hypotension. Group III patients experienced actual cardiac arrest and were resuscitated by portable femoral arteriovenous cardiopulmonary bypass. In group I three of eight patients died, in group II one of six patients, and in group III two of three patients. There were two late deaths at two and three months postoperatively. Operation in the face of acute myocardial infarction has been successfully employed in a selected group of patients.